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~5 <br />PERMITI"EE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />July 22, 2004 <br />RECEf VED <br />AUG18~ <br />ti:;:L:. ,t :.;,.... <br />.. _.,.: JzotalY <br />$688.00 (Due on or before your anniversary date) <br />Motfat <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 <br />__ . _ .npera[or_shall submit_the annual fee, a_report. and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 su~cefor a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact:' Wes Hertzog <br />Pemuttee Name: Wes Hertzog Trucking <br />Address: <br />Phone Number: <br />~Fas Number: <br />814 Stout St. <br />Craig, CO 81625 <br />(970)824-5201 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it [o this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corpo t Off cer or Owner <br />~ /~~~- <br />Date <br /> <br />ANNUAL FEE and REPORT REQUEST <br />Wes Hartzog Trucking <br />M-1981-276 <br />~` Hertzog Pit ~ `- <br />