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ANN AL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />47ount Royale Ventures, LLC <br />? -1983-141 <br />Cash & Who Do Mines <br />September 7, 2009 <br />01 <br />? I;:.:tl <br />?0,1 <br />!V <br />$$259.00 (Due on or before your anniversary date) <br />Boulder <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 man 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 chances 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 Contactc-Matt Collins <br />?h,?ne 303 S'lo 6.2 6`?) <br />Permittee Name: Mount Royale Ventures, LLC <br />Address: P.O. Box 19754 <br />Boulder, CO 80308 - 2-T s Q- <br />Phone Number: (720)-5-6< 3c? 3 S « 3-14-- <br />Fax Number: _ 20) 545 3404-- -6e?Q- 66S ooo5 <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 />Signature of Corporate ficer, Owner, or Designee <br />Date <br />M:\PERN ET\MASTERDOCUMENTS/M-AF-02.DOC