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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />AF- '.- Q? r <br />ANNUAL FEE and REPORT RE UEST <br />X??Seifert Construction <br />M-1985-040 <br />Seifert Pit <br />June 18, 2010 <br />IECOVE <br />JUN 0 4 2090 <br />Division of Roalwajj@i1, <br />Mining & Onfogy <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 man to this form The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />man. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new may is required 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: Mary-Seifert <br />f r c'7"' S te) <br />Permittee Name: Seifert Construction <br />Address: P.G. Box 305 PP. x 0 <br />Westcliffe, CO 81252-0305 <br />Phone Number: (719) 783-2757 <br />Fax Number: (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 alo your written report and map. Annual Report instructions are enclosed. <br />Sign re of ? rate Officer, Owner, or Designee <br />Date