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4jr- <br />AN AL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />asthofFarms <br />Z-1987-166 <br />Westhoff Farms <br /> <br />ti -w•-6?, ?tid <br />r10V w 3 <br />December 1, 2010 1vision of R.^cia 'iat;on, <br />$$323.00 (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-aeeomplished to-date-and- during the-precedin a , new?ig`fur ance's-that`are an-icipaTe-fi o of- ccu- <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. 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 during the previous year and no new changes to <br />ljthe previous year's map are necessary, 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 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: Westhoff Farms <br />Address: 2823 CR 3 <br />Wiggins, CO 80654 <br />Phone Number: (970) 483-5561 <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 />Signature of Corpo at fficer, Owner, or Designee <br />0-o5 EP14 W :E.s- 4 of-F <br />Date 1 r -:Z,7- / -) <br />0 UFQ"? <br />