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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Wes Hertzog Trucking <br />M-1981-276 <br />Hertzog Pit <br />July 22, 2003 <br />RECEIVED <br />JUL 1 1 2003 <br />Division ~f Minerals anA Geology <br />$688.00 (Due on or before your anniversary date) <br />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 operator _ <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamati4n_accomplished_t~date-and during the preceding yeaz,.new disturbances-tha[_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 y9nr revised written anneal rennet and annual rennet m ~n to this form. Please note that an <br />adequately Labeled map that clearly delineates and inc/odes 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: Wes Hertzog <br />Permittee Name: Wes Hertzog Trucking <br />Address: 814 Stout St. <br />Craig, CO 81625 <br />Phone Number: (970) 824-5201 <br />Fax Number <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 Corpora e O tc r, Owner, or Designee <br />7-~ of <br />Date <br />M:~PERMn1MASTERD000MENTSVv1-AF-OI <br />