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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />tr; R?r <br />ANNI AL FEE and REPORT REOUEST <br />alais Resources Colorado, Inc. <br />- 1977 -410 <br />Cross Gold Mine <br />November 3, 2009 <br />$$259.00 (Due on or before your anniversary date) <br />Boulder <br />QGS <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 pre new dis that a _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 may 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: Thomas S. Hendricks <br />VICE ftblftw3 -64w <br />Permittee Name: Calais Resources Colorado, Inc. <br />Address: 4415 Cross Mine Road <br />P.O. Box 653 - Caribou <br />Nederland, CO 80466 -0653 <br />Phone Number: (303) 258 -3806 <br />Fax Number: (303) 258 -0402 <br />have additional comments and /or information that should be provided to the Division, please provide it <br />or attacol to this form along with your written report and map. Annual Report instructions are <br />5. <br />Signature of C orate Officer, Owner, or Designee <br />Date <br />M:IPERMITVMAS TERDOCUMENTSIM- AF -02. DOC <br />