REP07813

• Permit No: M1999069
• IBM Index Class Name: Report
• Doc Date: 1/9/2004
• Doc Name: Annual Fee/Report Notice
• From: Jake Kauffman & Sons Inc.
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
Jake Kauffman & Son, Inc.
M-1999-069
Wagner/Kauffman Pit #3
January 5, 2004
$688.00 (Due on or before your anniversary date)
Larimer

RECEIVED
JAN 0 9 2004
piviaian of Minerals & Oeolopy
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 I
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation-accomplished-to-date and-during-the-preceding-year,-new-disturbances-that-are-anticipated-to-occur I
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any.
Please attarh ymn• revised written anmral reo~rt and annual renort mad to this fnrm_ Please note that an
adequately labeled map that clearly delineates and includes the above elements may sufftce for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Mary Kauffman
Permittee Name: Jake Kauffman & Son, Inc.
Address: 808 SCR 9E
Loveland, CO 80537
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
Signam~r~il Oo ate Offic ,Own r, or Designee
Date
M:\PERMITMASTERDOCUMENTSV.I-AF-01