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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />John O Buckner <br />M-1993-030 <br />Crystaljack Mine <br />April 26, 2004 <br />~5 <br />RE~'~~" ~~D <br />APR ~ b ~u04 <br />DiVi5i0aof hiu.c,n,.,. deolopy <br />$75.00 (Due on or before your anniversary date) <br />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 <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 ~nnr revised written annnal rennr and annnal r nnrt m:fp fn this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: John O. Buckner <br />Permittee Name: John O Buckner <br />Address: 2516 Waldean St. <br />Colorado Springs, CO 80909-4015 <br />Phone Number: (719) 634-4042 <br />Fax Number: (719) 634-5431 <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 />I rature of o p e Officer, Owner, or Designee <br />~ /J zo6~. <br />Date <br />M:IPERMITMASTERDOCUMENTS/M-AF-02.DOC <br />