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<br />ANNUAL FEE and REPORT REQUEST <br />JUL 18 2W2 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />James VanElla <br />M-1992-045 <br />Gold Basin Mine <br />July 21, 2002 <br />RECEIVED <br />Division of Minerals and Geology <br />$75.00 (Due on or before your anniversary date) <br />Chaffee <br />According [o C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on [he anniversary date of the permit, an <br />land, reclamation accomplished [o date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation [hat 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 annual report and annual report map to this form. Please note that a/t <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'Con[act James VanElla <br />Permittee Name: James VanElla <br />Address: 180 Ln. 200 Bass Lake <br />Angola, IN 46703 <br />Phone Number: (219) 665-7060 <br />Fax Number: <br /> <br />~-~ to io- <br />P o. /~o x as ~ / <br />Cf"~/ilhuse....r- _,c.r,~e, l~f2P s~ <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 />?7 <br />ignature of Corporate Officer or Owner <br />7 16 - o Z <br />Date <br />M:NERMITIMASTER DOCUMENTS/M-AF-02. DOC <br />