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i~~C~e~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />John R. Kurtzer <br />M-2002-053 <br />Kurtzer Pit <br />November 27, 2003 <br />$281.00 (Due on or before your anniversary date) <br />Phillips <br />ocr Z i zoo3 <br />Division of Minerals and Geolo~~~ <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-thc-extent-of-current-disturbanees-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 yfyrr revised written anneal rennrt and anneal report m ~n to this form. Please note that an <br />adequately labeled map that clearly delineates 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: John R Kurtzer <br />\Permittee Name: John R. Kurtzer <br />Address: 24463 CR 11 <br />\ ~Iiaxtun, CO 80731 <br />Phone Number: (970) 774-7122 <br />--- Faz Number: - `Z9'10) 774=3265~- <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 />S lure of Corporate ficer, weer, or Designee <br />~~ , `~'/ - <br />Date <br /> <br />M:~PERMITMASTERD000M ENTSVvt-AF-01 <br />