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i ~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~ ~ ~ P~ <br />ANNUAL FEE and REPORT REQUEST <br />i Gold Mountain Metals, Inc. <br />M-1992-045 <br />~~ <br />Gold Basin Mine <br />July 21, 2007 <br />~1L_- <br />RECEotp~C <br />'~JUL 12 2007 <br />0pvi~ion of Reciamation, <br />`iNining and Safety <br />$$225.00 (Due on or before your anniversary date) <br />Chaffee <br />acc'ordin`g [o C:R:S-34=32:5=i 16'or C:R:S'34~2=1-16,-each'year,'onrthc-anniversary date'oftl-ieperrrrit, 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 year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances to the previous year's map are necessary. then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffcefor a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Steven M. Ryba <br />Permittee Name: Gold Mountain Metals, Inc. <br />Address: P.O. Box 29 <br />Sharon Center, OH 44274 <br />Phone Number: --f330j336.8774- ~ ~~ - ~~ ~.~. ` ~ 3 oZ <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 />-~~ <br />Signature of Corporate Officer, caner, or Designee <br />~~~s/o~- <br />Date <br />M:IPERMITMA SrERDOCUMENfS-AF-02. DOC <br />