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/~ h~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~ANNiiAf. FF,F, and RF.PnRT RF.niTF.ST <br />/Georgia Rubeck -Walt Rubeck <br />v M-2002-003 <br />Topaz Mt. Gem Mine <br />March 26, 2006 <br />REGE°~~;~~ <br />~ MAR 13 ~_,;.,~ <br />~airision of Mirterels and Gealo~y <br />$225.00 (Due on or before your anniversary date) <br />Park <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 />«a ..,.1 .........:...... «l:..l. .] .7 f .i .7 kl. - tel. . <br />, ~T= U-\/Pa Y-nPW-(lich mhanrrc ~}lat aYP-IlP}IC1nafP~'}(1 <br />occur during the upcoming year, reclamation that will be perfotrned 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 ynnr revised written anneal report and annual report map 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 pertnittee contact information. Please verify and make any necessary <br />changes: .~/ ' / <br />/6t i5 wl// t~/.//J9 L' J~D : L/ <br />Permittee Contact: Walt Rubeck O <br />Permittee Name: Georgia Rubeck -Walt Rubeck <br />Address: 2010 Wold Ave. <br />Colorado Springs, CO 80909 <br />.Phone Number: - (719) 596-5492 <br />Fax Number: <br />r.IG~P,C ~ ~ Dt~.£'.PiS <br />z~zo ~~~/ //fS D~~ <br />~r9) rv SS -- Yv7 <br /> <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, Owner, or Designee <br />u{' /L/i/// t'lG <br />Date <br />i C~/Y( .s ~~ X77/ /T i~/L <br />yi9Sk~' pia ~ ~~. <br /> <br />GL <br />,/~ S H /" <br />M:WERMI7IMASTERDOCUMENTSMf-AF-02.DOC <br />