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~' <br />~N <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 vear,.new disturbancecthat.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 ymir revised written annual rennrt and annual re~nrt 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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: <br />George E. Often <br />George E. Often <br />Address: <br />11438 CR 19 <br />Fort Lupton, CO 80621 <br />Phone Number: (970) 785-2538 <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 <br />George E. Otters <br />M-1984-013 <br />Mackey Mine <br />May 14, 2004 <br />APR 0 8 2b04 <br />®itllSlon of Minerals anG ~,.,_~,~, <br />$225.00 (Due on or before your anniversary date) <br />Gilpin <br />or Designee <br />~~ '®7 <br />Date <br />M: W ERMI7IMASTERD000MEMS/M-AF-02.DOC <br />