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AV <br />ANNU' AL FEE and REPORT REQUEST <br />PERMITTEE NAME: Jack Pine Mining Company `? C?-= 0, P- f F?7 F0 <br />PERMIT NO.: PNI-1990-147 'FEW Q 0 ?Ong <br />OPERATION NAME: Mendota Properties Dlviuion of „r <br />Minim and 6'aQ.;g+ <br />ANNIVERSARY DATE: February 12, 2009 <br />ANNUAL FEE DUE: $$259.00 (Due on or before your anniversary date) <br />COUNTY: Clear Creek <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 />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 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: Fabyan Watrous <br />Permittee Name: Jack Pine Mining Company <br />Address: P.O. Box 66 <br />Idaho Springs, CO 80452-0066 <br />Phone Number: (303) 567-2350 <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 />Signatur of Corporate Officer, , , ori3ee <br />Date <br />M:IPERMIT\MASTERDOCUMENTS/M-AF-02. DOC <br />?o g,