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f4? -?- 6?P r- <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Seifert Construction +,,r <br />PERMIT NO.: M-1991-083 ,? / P 14 2004 <br />OPERATION NAME: Ula Pit ? SE <br />Division of Keclamation, <br />ANNIVERSARY DATE: October 29, 2009 Mining and Safety <br />ANNUAL FEE DUE: $791.00 (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 -that-w'ill-be performed durm` g tl-ie coming year, the daaes-for the 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 may 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 chanzes to <br />the previous vear's map are necessary, then no new map 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 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: .Je,aldQsfea <br />:f <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 alon with our written report and map. Annual Report instructions are enclosed. <br />Sign re of Corporate ficer, Owner, or Designee <br />R- - oCI <br />Date