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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Seifert Construction <br />M-1991-083 <br />Ula Pit <br />October 29, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Custer <br /> <br />RECEIVED <br />OCT Z 8 2002 <br />Division of Minerals and Geology <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-1 ]6, each year, on the anniversary date of the permit, an operator <br />- shall submit_the annual_fee,_a report._and map sho.wing.the_extent_of_Current_disturbances~o_affected_land, - <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation [hat will be performed during [he 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 apt <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following pemtittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact <br />Permittee Name <br />Address: <br />Mary Seifer[ <br />Seifert Constmction <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 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 />~~ 1~.,(~ ~Q ~-~~ <br />Signatp>e of Corporate Officer, Own~Destgnee <br />~~ ~~ _ ~ L(-~ ~ <br />Date <br />M:~PERM171MASTERD000MENTSNI-AF-01 <br />