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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Siegrist Construction Company <br />M-1982.015 <br />Siegrist Const Co <br />December 10, ZOOZ <br />DECEIVED <br />FEg ~ g 2003 <br />Givisian a/Minerals and Geolo9Y <br />$688.00 (Due on or before your anniversary date) <br />Weld <br />According [o C.R.S. 34-32.5-] 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 [o date and tlucing the preceding year, new disturbances that are anticipated to occur <br />during the upcoming yeaz, 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 permi[tee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Mike Siegrist <br />Permittee Name: Siegrist Construction Company <br />Address: 875 W. 64th Ave. <br />Phone Number: <br />- -Fax Number: <br />Denver. CO 80221 <br />(303)427-8472 <br />(303)428-8542 <br />If you hav itional comments and/or information that should be provided to the Division, please provide it <br />below tach it o this form along with your written report and map. Annual Report instructions are enclosed. <br />of Corporate Officer, Owner, or Designee <br />~/U <br />Date <br />MINER M ITUA ASTERDOCUM EMSVN-AF-OI <br />