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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Ron Ebberts <br />M-1980-038 <br />Disappointment Valle <br />October 1, 2003 <br />$281.00 (Due on or before your anniversary date) <br />San Miguel <br />SEP 2 9 X003 <br />piaisian of Minerals and p®olnOY <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 operator <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anneal report and annual rennrt main to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Ron Ebberts <br />Permittee Name: Ron Ebberts <br />Address: P.O. Box 250 <br />Egnar, CO 81325 <br />_ _Phone Number: _ (970) 6772476 <br />Fax Number: (970) 677-2776 <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 enclosed. <br />(.~~- ~ <br />Signature of Corporate Officer, Owner, or Designee <br />r~9-aa -03 <br />Date <br />M iPERMITMASTERDOCUM ENTSU4-AF-01 <br />