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~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />John R. Kurtzer <br />M-2002-053 <br />Kurtzer Pit <br />November 27, 2004 <br />~~ <br />OCT i ~ ?pp4 <br />Division of Minerals & GeolaDY <br />$281.00 (Due on or before your anniversary date) <br />Phillips <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-accomphshed-ta-date=and-dctrng=the preceding-year;-new-disturbances-that-are anticipated-to~ocenr <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 annnal re,~prt and annual re~nrt map 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: John R. Kurtzer <br />Permittee Name: John R. Kurtzer <br />Address: 24463 CR 11 <br /> Haxtun, CO 80731 <br />Phone Number: (970) 774-7122 <br />Fax Number: _ (970) 7743265 _ _- _ -- _ -- - ----- - - - "- ~" <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 />ature of Corporate Officer, caner, or Designee <br />9D ~ ~~/ <br />Date <br />