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<br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Seifert Construction <br />M-1993-027 <br />Schoolt`ield Pit <br />October 4, 2002 <br />OCT 01 2002 <br /> <br />llivisian of Minerals and Geology <br />$251.00 (Due on or before your anniversary date) <br />Custer <br />According to C.R.S. 34-32.5-I 16 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 4o dates and during-the-preceding year,-revrdisturbances-that-are-unticipsted-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 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: Mary Seifert <br />Permittee Name: Seifert Construction <br />Address: 198 Range View Loop <br />P.O. Box 305 <br />Westcliffe, CO 81252 <br />Phone Number. (719) 783-2757 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to [he Division, please provide i[ <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />~C,l-/k~1 ~1` <br />Signature of Corp ate Offic r, Owner, or Designee <br />~`~J-Oa <br />Date <br />M1PERMITVNASTERD000MENTSN~7-AF-O7 <br />