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~~ ~ ~~ ,~m~< ~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~~wa.fi<<g,~-<-~ <br />0 T 2 ~: 2C05 <br />$688.00 (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-I 16, each year, on the anniversary date of the permit, an operator <br />sY.aFl submit the annual fee, a report and map showing the -extent of -current disturbances3-t0-affected -lard, <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 ynnr revised written annual rennrt and anm~al rennrt map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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 Seifert <br />Permittee Name: Seifert Construction <br />Address: P.O. Box 305 <br />198 Range View Loop <br />Westcliffe, CO 81252 <br />Phone Number: (719) 783-2757 <br />Fax Number: (719) 783-2988 <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 />~~~ ~~ <br />Sig ature of orporat Officer, caner, or Designee <br />A~NNiiAi, FF.F, and REPORT RF.niTF.ST <br />~ Se' ert construction <br />[/M-1991-083 - <br />~,i: -_ <br />Ula Pit -.' <br />October 29, 2005 <br />Date <br />