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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: i/Jerry Johnston ~ _ ____ ~ ~~~~~pf^ <br />PERMIT NO.: (~I-1982-044 ~~PR 18 2001 <br />OPERATION NAME: Glen Johnston Site 1 ~iNsion of Reclamation, <br />~ Mining and Safety <br />ANNIVERSARY DATE: Apri123, 2007 <br />ANNUAL FEE DUE: $$281.00 (Due on or before your anniversary date) ~. <br />~~..:; <br />COUNTY: Teller _ <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_pxeceding_year, new disturbances that_are_anticipated to occur- __ <br />during the upcoming year, reclamation that will be performed during the coming year, the dates 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 resort 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 veer-and no new-changes to -- <br />the previous year'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: Jerry Johnston <br />Permittee Name: <br />Address: <br />Jerry Johnston <br />13800 Hwy. 24 <br />Phone Number: <br />Fax Number: <br />Divide, CO 80814 <br />(719)687-9043 <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 />~~~ <br />Si ture o~e Officer, Owner, or Designee <br />-cG-- c (-- 0-1 <br />Date <br />