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PERMIT <br />A RECE~ V ~® <br />TEE N <br />ME: Goose Haven Sand & Gravel, Inc. <br />PERMIT NO.: M-1984-099 NQ~ ~ 6 Z~3 <br />OPERATION NAME: Bailey Pit <br />als and Geology <br /> Division ~f Miner <br />ANNIVERSARY DATE: September 29, 2003 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Weld <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 anmlal re~rt and anneal renort m t to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Doug Tiefel <br />Permittee Name: Goose Haven Sand & Gravel, Inc. <br />Address: P.O. Box 17130 <br />Boulder, CO 80308 <br />Phone Number: (303) 665-9390 <br />Fax Number: (303) 665-0165 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />1,0/u.i <br />Date <br />M:~PERM ITU1 ASTERDOCUMENTSVN-AF-01 <br />