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~q 5 <br />RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />William E. Burnett <br />M-1978-222-UG <br />Monogram Mines <br />March 1, 2006 <br />$225.00 (Due on or before your anniversary date) <br />Montrose <br />FEB 1:, 2006 <br />pivision of Minerals and Geology <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~uring 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 your revised written anm~al report and annual re,Pnrt main in 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: William E. Burnett <br />Permittee Name: William E. Burnett <br />Address: 5002 Syndt Rd. <br />Evergreen, CO 80439 <br />Phone Number: (303) 697043 <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. ,~ /O C~~6~S <br />c11~ ~u,-- <br />Signature of Corporate Officer, wnev, or Designee <br />~~~-oG <br />Date <br />M:~PEAMIIIMASTERDOCUMENTS/IN-AF-02.DOC <br />