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_ .- ~ ~~ <br />`ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: / Seifert Coustruction <br />PERMIT NO ~ <br />~M <br />1991 <br />083 ~ • <br />.: • <br />- <br />- <br />~ ~ 1 n <br /> <br />OPERATION NAME: Ula Pit <br /> w <br />ANNIVERSARY DATE: _ _:~..October29,~2006 ~ <br />, <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: <br />Custer <br />~tn'o~ <br />il,~Al° <br /> <br />~, OCT 3 0 2006 <br />" Division of Reclamation, <br />Mining and Safety <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 man showing the extent of current disturbances to 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 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 your revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durinc the previous veer 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 Zabeled 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: Jerald Seifert <br />Permittee Name: Seifert Construction <br />Address: P.O. Box 305 <br />_ _ 198 Range_View Loop _ _ _ _ _ _ <br /> Westcliffe, CO 81252 <br />Phone Number: (719) 783-2757 <br />Fax Number: (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 />~~ ~~ <br />Signature of rporate fficer, O er, o Designee <br />D ' .~ i~, - <br />Date <br />