2009-03-20_REPORT - M1999003 - Laserfiche WebLink

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OlC ANNUAL FEE and REPORT REOUEST PERMITTEE NAME: Seifert Construction WC PERMIT NO.: M-1999-003 MAR 2 0 2009 OPERATION NAME: Tallahassee Pit Division of Reclamation, ANNIVERSARY DATE: April 8, 2009 Mitring and Safety ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) COUNTY: Fremont 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accom Dished to date and during the preceding year, new disturbances that are anticipated to occur, during the upcoming year, reclamation that wiTF5e per or-acme urmg t e coming year, e a es or e egim?mg of active operations, and the date active operations ceased for the year, if any. Please attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous year and no new changes to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Jerald Seifert Permittee Name: Address: Phone Number: Fax Number: Seifert Construction P.O. Box 305 Westcliffe, CO 81252- (719) 783-2757 If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. W) aAAA ? Signature f Corpo ate Officer, wner, or Designee Date