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~~ ~ ~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Jake Kauffman & S n, Inc <br />M-1978-327 <br />Kauffman Pit <br />May 14, 2008 <br />$$791.00 (Due on or before your anniversary date) <br />Larimer <br />~~~® <br />MAY 1 3 2008 I~ <br />Divislun u~ ~~eclamation, <br />MINng and Safety ,~ <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 accomplished to_ date and during_the_preceding-.year,...new--disturbances-that- are--anticipated ~o-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 vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durinE the previous year and no new changes to <br />the previous year's map are necessarv, then no new map is required, provided that the Operator shall. state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and Includes the <br />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: Mary Kauffman <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 />Signatur of orpo Officer, Ow er, or esignee <br />.5~ //~D~ <br />Date <br />