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kv ? Q?T <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Seifert Construction <br />M-1991-083 <br />Ula Pit <br />October 29, 2008 <br />$$791.00 (Due on or before your anniversary date) <br />Custer <br /> <br />OCT '14 zoua ? <br />Division u. .-, ?ia?nation1 ?j <br />{?i?ning and Safety ?/ <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 />-- durf??thtupcorriing yea ,-rer- clamationrth-at'wilrbe-performed unng a -coming year, -t e- da es or a beginning - <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour 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 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: Jerald Seifert <br />Permittee Name: Seifert Construction <br />Address: 198 Range View Loop <br />P.O. Box 305 <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 />Signature of orporate fficer, wner, or Designee <br />Date