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_> <br />RECEIVED <br />SEP 18 2003 <br />Division ~f Minerals and Geology <br />PERMITEE NAME: <br />PERMIT NO. <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY; <br />Asphalt Paving Co. <br />M-1990-098 <br />Perry Pit <br />September 29,2002 <br />$688.00 (Due on or before your anniversary date) <br />Weld <br />According to C.R.S 34-32.5-U6 or C.R.S. 34-31-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to <br />affected land reclamation accomplished to date and during the preceding year, new disturbances that are <br />anticipated to occur during the upcoming year, reclamation that will be performed during the coming <br />year, the dates for beginning of active operations, and the date active operations ceased for the year, if <br />any. <br />Please attach vour revised written annual report and annual report map to this form. Please note <br />that an adequately labeled map that clearly delineates and includes the above elements may suffice for a <br />written report. <br />Division records indicated the following permittee contact information. Please verify and make any <br />necessary changes. <br />Permitee Contact: Jeff Keller <br />Permittee Name: <br />Address <br />Phone Number: <br />ANNUAL FEE AND REPORT REQUEST <br />Asphalt Paving Co. <br />14802 W. 44`" Ave. <br />Golden, CO 80403 <br />303-279-66611 <br />Fax Number: 303-279-6216 <br />If you have additional comments and/or information that should be provided to the Division, please <br />provide it below or attach it to this form along with your written report and map. Annual Report <br />instructions are enclosed. <br />X ~~.~ <br />Signature of Corporate Office, Owner, or DesiQrt_ ee _~ <br />Date <br />