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<br />PERMti'TEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Jake Kauffman & Sons, Inc. <br />M-1978-327 <br />Kauffman Pit <br />May 14, 2002 <br />$688.00 (Due on or before your anniversary date) <br />Larimer <br />REGEIYED <br />MAY 14 200Y <br />Division o/Minerals and Geology <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 [o_affected land, . <br />reclamation accomplished to date and during the preceding year, new disturbances 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 vour revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the 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 />Permi[[ee 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 /> <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 repoR and map. Annual Report instructions are enclosed. <br />Signatur f Corporate Offta or Owner <br />Date <br />M iPERM I"nMASTERDOC UM [iNTSVN-AF-01 <br />