2007-10-24_REPORT - M1991083 - Laserfiche WebLink

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.Y`~ ~~ ~ ~~ ANNUAL FEE and REPO R T REOUEST ~ Q ~ PERMITTEE NAME: Seifert Construction / PERMIT NO.: / M-1991-083 ,/ OPERATION NAME: Ula Pit ANNNERSARY DATE: October 29, 2007 ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) COUNTY: Custer RECEI~/ED/ OCT 2 4 2001 Div~t~ gland Safety 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 reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach vour 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 durinc the previous year and no new chances to the previous year's map are necessary, then no new man 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 since 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: Seifert Construction Address: P.O. Box 305 __ 148 Range View Loop Westcliffe, CO 81252 Phone Number: (719) 783-2757 Fax Number: (719) 783-2988 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. Signature o Corporat Officer, O per, or Designee Date