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:-'r . <br />~, s <br />Y <br />]~' ~~ <br />U RECEIVED <br />MAR 19 2004 <br />Division of Minerals & Geology <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Siegrist Construction Company <br />M-1982-015 <br />Siegrist Const Co <br />December 1Q, 2003 <br />$688.00 (Due on or before your anniversary date) <br />Weld <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-thc-annual fee; a-repoR=and-map-showing" the-exfent=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 ym~r revised written anneal rennrt and anneal rennrt 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 permittee 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 />Denver, CO 80221 <br />Phone Number: <br />427-8472 <br />Fax Number: (303) 428-8542 <br />If you have onal co ents and/or information that should be provided to the Division, please provide it <br />below o ac tt to this fo along with your written report and map. Annual Report instructions are enclosed. <br />Si afore of Corporate Officer, Owner, or Designee <br />Date <br />M:\PERMITV.1ASTERD000MENTS\M-AF-01 <br />