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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~~ ~' <br />f <br />ANNiIAi. FF.F, and RF,P(lRT RF.ni1FST <br />Holcim (US) Inc. <br />/fi~I-1977-346 <br />Boettcher Gypsum Quarry <br />c b~'I <br />R~CEI VED <br />vSEP 2 g y~ <br />October 10, 2005 ~ Oiriyion of <br />Minerals end GwloQy <br />$688.00 (Due on or before your anniversary date) <br />Larimer <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 anneal re;~grt and annual report m to this form- Pleas¢ note that an <br />adequately labeled map that clearly dedineates 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: Gordon Benton <br />Permittee Name: Holcim (US) Inc. <br />Address: Project Manager <br />P.O. Box 1548 <br />La Porte, CO 80535 <br />Phone Number: (970) 482-4065 <br />Fax Number: (970) 482-1363 <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 />~~~ <br />Signature of Corporate Officer, Owner, or Designee <br />J - Z ~o - r"j <br />Date <br />