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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNiJAL FEE DUE: <br />COUNTY: <br />~~ ~- ~-P~ <br />ANNUAL FEE and REPORT REQUEST <br />Jake Kauffman & Son, Inc <br />M-1999-069 <br />Wagner/Kauffman Pit #3 <br />January 5, 2008 <br />(~~j Ire /~. q p <br />~~~ .~ 12®~~ ~ <br />b!b!t~1~~y 1>r F?ecla <br />MJt~ili~ ,,, mapron, <br />9 t rid l~afefy <br />$$791.00 (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 />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />__ _ -reclamation-accomplished-to-date-and-during-the-preceding year,-new disturbance`s -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 man to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />mau. 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 />Permittee Contact: Frank Kauffman <br />Permittee 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 />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 />Si atur o o ~ e Officer, O er, or Designee <br />~~~-~ ~ <br />Date <br />