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<br />ANNUAL FEE and REPORT REOUEST~~~~~V~® <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Colorado Quarries, Inc. <br />M-1987-026 <br />Black Obsidian <br />November 6, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Custer <br />~~V 0 8 ZQ~ <br />Division of Minerals and Geology <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Bill Tezak <br />Permittee Name: Colorado Quarries, Inc. <br />Address: 270 S. 15th St. <br />Canon City, CO 81212 <br />Phone Number: (719) 275-6894 <br />Fax Number: (719) 275-2131 <br />If you have additional comments and/or information that should be provided to the Division, please provide i[ <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of ~ ~ rporate Officer, Owner, or Designee <br />JO - i~ ~ o~ <br />Darnte / <br />/~/~~teT ~c'C./'~/9~//! ~ d h.. ~efiC h.'f1rE' <br />M:~PERMrIVNASTERDOCUMENTSUI-AF-01 <br />