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/T~y~~~ <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />JL/incoln Couuty <br />/M-1985-109 <br />Arthur L Schmeiser <br />August 6, 2007 <br />~~ <br />~~~~ 0~~~ <br />BUG 0 ~ 2007 <br />~i pion of keclamation <br />Mining and Safety <br />$323.00 (Due on or before your anniversary date) <br />Lincoln <br />Recording-to-C-.R:S-34-33:5-1-16-or-C-I2-S.-34-32-11b,-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 yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated man. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances to the previous year's map are necessary,then no new map is required, provided that the <br />Operator shall state this in the Annual Report, Please note that an adequately labeled map that clearly <br />delineates and includes the 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: -BerrBleke- <br />Pemuttee Name: Lincoln County <br />Address: P.O. Box 39 <br />Phone Number: <br />Fax Number: <br />Hugo, CO 80821 <br />(719)743-2337 <br />(719)743-2815 <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 />Si afore of Corporate OfScer, Owner, or Designee <br />D,tel~~~ <br />Kenneth Morrison <br />M:~PERMI'MiASTERDOC[1MEMNN-AF-04 <br />