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~N~ <br />,„ . <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />I~E~EIVED <br />James VanElla <br />M-1992-045 <br />Gold Basin Mine <br />July 21, 2004 <br />~~ - <br />JUL 1 9 2004 <br />n"":.u. ,, ,ci.e~rei: f~ GeoloBY <br />$225.00 (Due on or before your anniversary date) <br />Chaffee <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />eperater-shall-submit-the-annual fee-,-a-*eport-and-map-showing-the_extent-of-cucrent_distuxbances to_affected- <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />PJease attach ynnr revised written annnal re~rt and annual rennrt maTtn this Fnrm_ Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: James VanElla ~ w~ ~~,n ~~~.1 <br />Permittee Name: James VanElla ~~ <br />Address: P.O. Box 2221 <br /> Granite, CO 81228 <br />Phone Number: (219) 665-7060 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />~xl,,,, Jt _. ~O.,tt ~P~i. <br />gnature of Corporate Officer, Owner, or Designee <br />i ~ a o~ <br />Date <br />M:~PERMITN~]ASTERDOCUMEM$/M-AF-02.DOC <br />