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<br />/~ <br />RECEeVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Jerald Seifert and Fred Lowry <br />M-1999-003 <br />Tallahassee Pit <br />Apri18, 2004 <br />$281.00 (Due on or before your anniversary date) <br />Fremont <br />APROg~ <br />Division of Minerals and Geology <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-[he "annual`fee,'-a report- and map showing tfie 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 ^nnr revised written anneal rennrt and anm~al re~prt main to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffzce 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: Jerald Seifert and Fred Lowry <br />Address: P.O. Box 305 <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 Repor[ instructions are enclosed. <br />J ~. <br />Signature f Corporate Offic r, Owner, or Designee <br />Date <br />