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.~ <br />PERMTITEENAME: Jelen&Son,Inc. RLIiE~VE~ <br />PERMIT NO.: M-1983-011 <br />MAR 2 3 2005 <br />OPERATION NAME: Willow Creek Mine <br />ANNIVERSARY DATE: February 23, 2005 Uirision of MMerets and Geology <br />ANNUAL FEE DUE: $225.00 (Due on or before your anniversary date) <br />COUNTY: Lake <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to <br />- -occur during the-npeoming year reclamation-that-will be-performed_during_the_couvtlg_year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ym~r revised written annnal report and annnal report m ~n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact infotmation. Please verify and make any necessary <br />changes: <br />Permittee Contact: Kay Blecha <br />Permittee Name: Jelen & Son, Inc. <br />Address: Box 103 <br />Castle Rock, CO 80104 <br />Phone Number: CF.PR.telephone_number 3 0,3 g 8 Fl - 2: So 7 ~ <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 <br />enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />3 - iS- O ~ <br />Date <br />M:~PERMI7IMASlERDOCUMEMS/M-AF-02.DOC <br />