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1 • / I - <br />~~~~. - <br />. •,- ~.;r,.~ <br />. J <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Jake Kauffman & Son, Inc. <br />M-1999-069 <br />Wagner/Kauffman Pit #3 <br />January 5, 2005 <br />DEC 2 ~ ZC04 <br /> <br />$688.00 (Due on or before your anniversary date) <br />Larimer <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 />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming yeaz, 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 attachwm~r revised written sonnet rennrt and anm~al re nn rt m ~n 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 Kauffrnan <br />Permittee Name: Jake Kauffman & Son, Inc. <br />Address: <br />Phone Number: <br />Fax Number: <br />808 SCR 9E <br />Loveland, CO 80537 <br />(970) 667-1557 <br />(9"70) 667-9985 _ ' <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 />Date <br />