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<br />ANNIiAi <br />FTcF and REPORT RROT1Ti <br />ST RECEIVED <br /> , <br />, JAN 0 9 2006 <br />PERMITTEE NAME: Jake Kauffman & Son, Inc. <br />aratMinerats~'~~9Y <br />PERMIT NO.: M-1999-069 <br />OPERATION NAME: Wagner/Kauffman Pit #3 <br />ANNIVERSARY DATE: January 5, 2006 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Lorimer <br /> <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 />- -shah-submit-the~rmuat-flee,-a-report and-reap 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 anm~al red nrt and anneal re,Pnrt man to this form. Please note that an <br />adequately labeled map that clearly delineates and includes 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: Frank Kauffinan <br />Permittee Name: Jake Kauffman & Son, Inc. <br />Address: 808 SCR 9E <br />Loveland, CO 80537 <br />Phone Number: (970) 667-1557 <br />Fax Number: (970) 667-9985 <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 />~~~ ~ ~ ~ ~~~~~y <br />Signatur of Corporate Office ~, Owner, or Designee <br />= os' as ®~ <br />Date <br />