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W .i- P'l- <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Seifert Construction <br />PERMIT NO.: M-1993-027 SEP 14 2009 <br />OPERATION NAME: Schoolfield Pit pin oi K-eciamation, <br />ANNIVERSARY DATE: October 4, 2009 Mining and Safety <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: 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 tliat will-be pdrformed`during the` coming year; the dales 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: . <br />'(-c "?M . S"?o r C\ <br />Permittee Name: Seifert Construction <br />Address: 198 Range View Loop <br />P.O. Box 305 <br />Westcliffe, CO 81252 <br />Phone Number: (719) 783-2988 <br />Fax Number: <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 />gnature of orate Officer, Owner, or Designee <br />c-R-oG <br />Date