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~5 <br />,/ ANNUAL FEE and REPORT REQUEST <br /> ~ <br />PERMITTEE NAME: William E. Burnett <br />PERMIT NO.: / M-1977-293 <br />OPERATION NAME: Monogram-Jo Dandy <br />ANNIVERSARY DATE: November 27, 2006 <br />ANNUAL FEE DUE: $225.00 (Due on or before your anniversary date <br />COUNTY: Montrose <br />wr~slZ <br />/o -~~-~ <br />RECEIVED <br />~ocr ~ s zoos <br />Dlvla(on of Reclamation, <br />M(n(ng and Safety <br />~~ <br />c~w~~ <br />_-_ __ Accord~g to C'„R.S_39_32.5-11.G_or_C.R.S.34-32-1-1.6,-each-year; on-the-anntversairy-gate-afthepcrmit; 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 vour revised written annual report and annual report man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinc the previous vear 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 suffice for a written report. f~ C ~~ 6 ~S <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) 697-4043 <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. Annua] Report instructions are <br />enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />/D -/Z -0 6 <br />Date <br /> <br />M:~PERMITUTASTERM)CUMENTS/M-AF-02.DOC <br />