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i � Ill l 11 l 11 l 11 llll 111 999 X'/A/ <br /> V <br /> ANNUAL FEE and REPORT REOUEST RECENED <br /> OCT 2 5 2CC11 <br /> PERMITTEE. NAME: Seifert Construction <br /> Division of Minecais and Geology <br /> PERMIT NO.: M-1991-083 <br /> OPERATION NAME: Ula Pit <br /> ANNIVERSARY DATE: October 29, 2001 <br /> ANNUAL FETE DUE: $281.00(Due on or before your anniversary date) <br /> COUNTY: Custer <br /> According to C.R.S. 34-32.5-116 or C.R.S. 34-32-1 16, 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 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. Please note that an <br /> adequately labeled map that clearly delineates and includes the above elements may suf ce 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 /> Pennittee Name: Seifert Construction <br /> Address: 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 /> Signature of CorP or e Officer or bwner <br /> / Q - >3- o1 <br /> Date <br /> Al'PERMrMASTERUOCUMEN'rSN1-AF01 <br />