2010-11-15_REPORT - M2002053 - Laserfiche WebLink

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PERMITTEE NAME PERMIT NO.: AN AL FEE and REPORT REOUEST John R. Kurtzer I/ /M-2002-053 ? v 'Sl "r I n OPERATION NAME: Kurtzer Pitf ANNIVERSARY DATE: November 27, 2010 o! ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) COUNTY: Phillips 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 shall submit the annual fee, a repo and map showing the extent of euffent antes-te-affected land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur 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 attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous year and no new changes to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: John R. Kurtzer Permittee Name: John R. Kurtzer Address: 24463 CR 11 Haxtun, CO 80731 _ _ Phone Number: (970L774-7122 Fax Number: (970) 774-3265 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. Signature of Corporate Officer, ner, or Designee / / Z?e_ X0 Date