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~F ~ RPM <br />ANNUAL FEE and REPORT REQUEST <br />RMITTEE NAME: Jelen & Son Inc. <br />PE , <br />PERMIT NO.: M-1983-011 ~/ <br />OPERATION NAME: Willow Creek Mine <br />ANNIVERSARY DATE: February 23, 2008 <br />ANNUAL FEE DUE:. $$259.00 (Due on or before your anniversary date) <br />COUNTY: Lake <br />RECEIVE® <br />FEB 2 ~ 2008 / <br />Division of Keclamation, ~j <br />Mining and Safety ~/ <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 />~'~»eratO~Shall c»hmit tl~P al~niial fae~~p~+~ +~ ~++a gip.-„c~]pw+„",b l:°-r;;tei2t O~CI::etl diS~uil'ial'iCc3 tG affcCiBd ---- <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 your revised written annual report and annual report map 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 during the previous year and no <br />new changes 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. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: :Kay Blecha <br />Permittee Name: .Jelen & Son, Inc. <br />Address: P.O. Box 103 <br />Castle Rock, CO 80104 <br />Phone Number: (303) 888-2507 ~lsO ~ 3 ° 3 - Z d~6 ' d96 ~"'~ <br />Fax Number: (303) 286-8688 <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 />~~~~ <br />Signature of Corporate Officer, Owner, or Designee <br /> <br />Date <br />M: ~PERMIT~fASTERDOCUMEiNTS/M-AF-02. DOC <br />