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h~ <br /> ANNIIAT, FF.F, and RF.PnRT RFt7i1F,ST ~ L <br />"~.~P~1V,~;(rT <br />PERMITTEE NAME: Seifert Construction SUN 2 ~ 2005 <br />PERMIT NO.: M-1985-040 Diviaior, of dp,,;~;~~s $ tiGnlu <br />OPERATION NAME: Seifert Pit <br />ANNNERSARY DATE: June 18, 2005 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: 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 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 beginninl~ <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anm~al report and annnal report masn, to this form. Please note that ari <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following pertnittee contact information. Please verify and make any necessar} <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: (719) 783-2757 <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 />-~V~ ~ ~~ <br />Signature Corpora e Officer, weer, or Designee <br />~~\S-~~ <br />Date <br />