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~S <br />ANNiiAT. FF.F, and RF.PnRT RF.nTTRST <br />Westhoff Farms <br />M-1487-166 <br />Westhoff Farms <br />December 1, 2004 <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUN'T'Y: <br />,~ ` <br />GF~~ ~ ` %l,iiq <br />na,.isi~a of f.:i~x- ~ 1, C.. ~F <br />'VYJ <br />$281.00 (Due on or before your anniversary date) <br />Morgan <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 />- - reclamation-aecemplished-te-date-ard-durng-flee-pr~eeding year,-new-disturbances-thaEare-anticipated-te-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 ynnr revised written anmeal red n~ rt and annnal rennrt main 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: Joseph E. Westhoff <br />Permittee Name <br />Address: <br />Westhoff Farms <br />2823 RD3 <br />Wiggins, CO 80654 <br />Phone Number: (970) 483-SS61 <br />Fax Number: (970) 483-5561 <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 />~7,~ -_ -~ <br />Si ature of Corporate Officer, Owner, or Designee <br />~ ~ /~~ <br />Date ~ <br />dL~ ~»T~u 1Tt~ <br />D.'~a~~~~ ~~~ ~o ~~ <br />.h1 °~, ~; <br />