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<br />ANNUAL FEE and REPORT REQUEST <br />RECEIVE® <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Wes Hartzog Trucking <br />M-1981-276 <br />Hertzog Pit <br />July 22, 2002 <br />$688.00 (Due on or before your anniversary date) <br />Moffat <br />JUL 2 2200'1 <br />Division of Minerals and Geningy <br />According to C.R.S. 34-32.5-] 16 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 />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 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 since far 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 Tracking <br />Address: 814 Stout St. <br />Craig, CO 81625 <br />Phone Number: (970) 824-5201 ,~ r 2 <br />Fax Number: (94~L' / y ~ ~~"~~ ~I ~~yl-~~ <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 />l~ ~ <br />Signa/tu/re ofgCo~rporat Of rc r or Owner <br />Date <br />MiPERMITU4ASTERD000MENTSNI-AF-OI <br />