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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />F *i- RPT- <br />ANNUAL FEE and REPORT REOUEST <br />Seifert Construction ? <br />M-2002-122 ? <br />Boyer Pit <br />July 23, 2009 <br /> <br />,? JUN 2 6 2009 <br />Division of %clamatiow, <br />Miring and Safety <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 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 previous vear's man 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 />41kl OL/? <br />Signature of C rporate Of icer, Owne , or Designee <br />(", ? <br />Date