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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Seifert Construction <br />M-1991-083 <br />Ula Pit <br />October 29, 2004 <br />RfCE1 VED <br />OCt 2 6 2~q <br />Division ~f Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Custer <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 />- reclamatior. 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 comiag 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 red ort and anm~al re~nrf TA: to this form- Please note that att <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: Jerald Seifert <br />Permittee Name: Seifert Construction <br />Address: P.O. Box 305 <br />Phone Number: <br />Fax Number: <br />198 Range View Loop <br />Westcliffe, CO 81252 <br />(719)783-2757 <br />(719) 783-2988 <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 />Signatur of Corp rate O tcer, Owner, or Designee <br />Date <br />