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AL FEE and R-fPORT REOUEST <br />PERMITTEE NAME: 1 cier Peak Art, Gems & Minerals <br />PERMIT NO.: 2002-003 <br />OPERATION NAME: Topaz Mt. Gem Mine <br />ANNIVERSARY DATE: March 26, 2010 <br />c/b z ? <br />W*VW <br />'*/MAR 15 2010 <br />Division of Reclamation, <br />/ V Mining and Safety <br />ANNUAL FEE DUE: $$259.00 (Due on or before your anniversary date) <br />COUNTY: Park <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 may 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: Joseph L. Dorris <br />Permittee Name: Glacier Peak Art, Gems & Minerals <br />Address: 2920 Cedar Heights Dr. <br />Colorado Springs, CO 80904 <br />Phone Number: (719) 685-4479 <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 />gnature of Corporate Officer, Owner, or Designee <br />i0?l.P?Zoio <br />Date <br />M-TERMITIMASTERDOCUN ENTS/M-AF-02.DOC