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0)V- <br />M1 <br />• 1 f I /? <br />ANNUAL FEE add PORT REQUEST U SO, <br />PERMITTEE NAME: 'Seifert Construction ''?(//1/ ED <br />PERMIT NO.: ---M-1985-040 P*i n c, 200, <br />OPERATION NAME: Seifert Pit a rr hbn <br />ANNIVERSARY DATE: June 18, 2008 <br />ANNUAL FEE DUE: $$791.00 (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 />_ reciainatiwi accomplish`ed--to da a and' duringthe preceding year, new istur ances t at 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. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the may reviousear's is requireare necessary, then no new map d, provided that the Operator shall state are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Mary Seifert <br />Permittee Name: Seifert Construction <br />Address: P.O. Box 305 <br />Phone Number: <br />Fax Number: <br />Westcliffe, CO 81252-0305 <br />(719) 783-2757 <br />(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 />Signature of orporate fficer, O er, or Designee <br />1 6 -O F <br />Date