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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />4:41;7 *-- Rer <br />ANNUAL FEE and REPORT RE UEST <br />Ron Ebberts ? <br />M-1980-038 .-1/ <br />Disappointment Valle <br />October 1, 2009 <br />§kFCtD <br />?? SEP 2 8 2009 <br />Division OT Reclamation, <br />Mining and Safety <br />$323.00 (Due on or before your anniversary date) <br />San Miguel <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />- - roc-edmg-`yeat;'rte?w-dsturbax?c ? ?'-.- =d"t?ccrzr---`"-?' <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 your revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous vear's man are necessarv. then no new man is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Ron Ebberts <br />Permittee Name: Ron Ebberts <br />Address: P.O. Box 250 <br /> <br />Egnar, CO 81325 <br />Phone Number: <br />Fax Number: <br />(970) 677-2476 <br />(970) 677-2776 <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 />? 0), X"ic <br />Signature of Corporate Officer, Owner, or Designee <br />9'? ??S- 09 <br />Date