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~- ~.-. • ~ III I III IIIIIIIII III • •\ _ 05 N ~ 5s o °° <br />sss Z a-o-° \ <br />ANNUAL REPORT ~§ I r t ° ~ ~ `~~ <br />PERMITTEE NAME: Siegrist Construction Company <br />RECEIVED <br />PERMIT NO.: M-S2-015 <br />OPERATION NAME: Siegrist Const Co N~~ 2 2 2~~ <br />ANNIVERSARY DATE: December 10, 1999 Division of Minerals aed Geology <br />ANNUAL FEE DUE ON ANNIVERSARY DATE: $550.00 <br />COUNTY: Weld <br />According to C.R.S. 34-32.E-1 16(3)(a), 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 <br />land, reclamation accomplished to date and during the preceding year, new disturbances that aze <br />anticipated to occur during the upcoming year, reclamation that will be performed during the coming <br />year, the dates for the beginning of active operations, and the date active operations ceased for the year, <br />if any. <br />Please attach your revised annual report map and written report to this annual report. Please <br />note that nn ndequntely labeled nrnp that clearly delineates nrrd includes the above elements Wray <br />suffice for a written report. <br />Please type or print the current contact person's name, mailing address, and phone number in the space <br />provided: <br />Con[actName: l \~1CG ~LCZ~iZIST Company: ~ic~•?~~ I C c..~e:-. ~~ <br />Adddr~ess: ~~ s W (o~F't' Al1-P . Phone No.: (~~) ~~ ~ - ~s`7:Z <br />t.~4~1`1`°~~ ~c ~c~Z~~U ~Jll FaxNo.:(3c3) ~~7-~S`~Z- <br />If there are additional comments and/or information that should be provided to [he Division, please <br />provide it on a separate sheet and attach it to this report form along with your map and/or written <br />report. ~-~ <br />~~~ z G - Gu <br />of Corporate Officer, or Owner <br />Date <br />INSTRUCTIONS ON BACK <br />