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v ANNUAL FEE and REPORT REQUEST <br />r? M~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />v Seifert Construction <br />'~M-1993-027 <br />Schoolfield Pit <br />October 4, 2006 <br />~~L <br />/b - Jb -C}o <br />RECEIVED <br />~l~'~z ~ 9 7rl~g <br />Y Division of Reclamation <br />Mining and Safety <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 />- -- -reclamation accomplished to date an during the preceding year, new disturbances 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 vour revised written annual report and annual report maa to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />man. If no new disturbances or reclamation have occurred durinc the previous year and no new chances 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 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 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: ~ ~ ~' ~ ~ 3 - ~ ~ ~ g <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 />~\ <br />Signature of orl!porate rr fficer, O er, or Designee <br />~~~b-~b <br />Date <br />