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IIIIIIIIIIIII III • <br /> 0 0 .1NUAL FEE and REPORT REOUEST RECEIVED <br /> (1 JUL 2 0 1001 <br /> PERMITTEE NAME: Wes Hertzog Trucking <br /> PERMIT NO.: #041981-276 Division of Minerals and Geology <br /> OPERATION NAME: 0 Hertzog Pit <br /> ANNIVERSARY DATE: July 22,2001 <br /> ANNUAL FEE DUE: $688.00(Due on or before your anniversary date) <br /> COUNTY: Moffat <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 /> operator 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 are 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 /> 0 <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 <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and make any necessary <br /> changes: <br /> Permittee Contact: Wes Hertzog <br /> O <br /> Permittee Name: Wes Hertzog Trucking <br /> Address: 814 Stout St. <br /> Craig, CO 81625 <br /> O Q �7 <br /> Phone Number: (309) 824-2623 / / zq` �� 201 <br /> Fax Number: (970) 677-2422 <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 Repott instructions are <br /> enclosed. <br /> Signature of C orate f cer or Owner <br /> s — s— <br /> Date <br /> M SPERM rRMASTERDOCUME-rSN.AF-01 <br /> 0 <br />