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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: John R. Kurtzer <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />John R. Kurtzer <br />24463 CR 11 <br />Haxtun, CO 80731 - <br />(970) 774 -7122 <br />(970) 774 -3265 <br />S'nature of Corpo ate 0 icer, Owner, or Designee <br />// /,o /J/ <br />Date <br />RPf <br />ANN 1 AL FEE and REPORT REQUEST <br />John R. Kurtzer <br />/M-2002-053 <br />Kurtzer Pit <br />November 27, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Phillips <br />1N011 18 2011 <br />Division of Reclamation, <br />Mining 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 />-reclarnration recHe -date -arid- during the- preeeding- -Fear new- distur-bances--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 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 />the 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 />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 />