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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Seifert Construction F <br />M-2002-122 <br />Boyer Pit <br />July 23, 2008 <br />RECEIVED <br />JUL 2 3, 2008 <br />DiWsion of Redatnafion, <br />Mkft and Sak? <br />$$791.00 (Due on or before your anniversary date) <br />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 yearar rec amatio`n that wi-il-be?perto" rmea duringa coming-year,=?he datesfor - - <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 />may. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous vear's map are necessarv, then no new man is reauired, provided that the Operator shall state <br />this 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: Jerald A. Seifert <br />Permittee Name: Seifert Construction <br />Address: P.O. Box 305 <br />- - Westcliffe, CO 81252 <br />Phone Number: (719) 783-2757 <br />Fax Number: (719) 782-2988 <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 />-4-v" <br />Signature of orporate Officer, Owner, or Designee <br />= a a- C) <br />Date