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RECEIVEp <br />ANNUAL FEE and REPORT REQUEST <br />APR 19 2002 <br />Division of Minerals and Geology <br />PERMTTTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Jerry Johnston <br />M-1982-044 <br />Glen Johnston Site 1 <br />April 23, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Teller <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of [he permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />-reclatnation•aecomphslted-to-date-and-during-the preceding-year;-newilisturb'ances [fiat are a'nticipa`ted [o 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 vour revised written annual report and annual report map 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: Jerry Johnston <br />Permittee Name: Jerry Johnston <br />Address: <br />Phone Number: <br />Fax Number: <br />13800 Hwy. 24 <br />Divide, CO 80814 <br />(719)687-9043 <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 />Date <br />Officer or Owner <br />M:~PERM rnMASTERDOCUMEMSUt-AF-01 <br />