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a1 "~ <br />PERMITTEE NAME: <br />PERMTI' NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />/ William E. Burnett <br />/M-1978-222-UG <br />Monogram Mines <br />March I, 2007 <br />~ FEB 1 ~ 2.t1A1 <br />pF3fl, <br />i Sri ~; .~ <br />$$225.00 (Due on or before your anniversary date) <br />Montrose <br />According to C.R.S. 34-32.5-116 or C_R.S. 34-32-116, each y_ear, p_nlhe~nniv~rsaty_daYe_ofthe n~rmir 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 vour 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 vear 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 suffice for a written report. <br />/Uo ~~~r~JG~S ~~r~ ~I1Jli ~' <br />Division records indicate the o lowing permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: William E. Burnett <br />Permittee Name: William E. Burnett <br />Address: 5002 Syndt Rd. <br />Evergreen, CO 80439 <br />Phone Number: (303) 697-4043 <br />~7~(--I3~1 °n- <br />Fax Number: 970 3J7 -~l~ ~z <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 />e~nc1~lo~7sed. ~~ ~~j <br />Signature of Corporate Officer, Owner, or Designee <br />a ~~a -o~ <br />Date <br />C~ <br /> <br /> <br />M:~PERMII~MASTERDOCUMENTS/M-AF-02.DOC <br />