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Ai-- *?'V <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />[Z/ <br />:/ James VanElla <br />M-1992-045 <br />Gold Basin Mine <br />December 26, 2010 <br />$259.00 (Due on or before your anniversary date) <br />Chaffee <br />=I 'I) E: D <br />VV <br />Le, Ji . r y. ' latitart, <br />;a <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 vour revised written annual report and annual report may 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: James VanElla <br />Permittee Name: James VanElla <br />Address: 180 Lane 200 Bass Lake <br />Angola, IN 46703 <br />021-5-j-- 9 01 d <br />Phone Number: (260) 66'666- 6 0 S 3'- 9 0 / c? <br />Fax Number: 904 5 C2 6Cj - J"-- 9002 <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 />lox L <br />gnature Corporate Offic ,Owner, r Designee <br />Date <br />M:\PERMITIMASTERDOCUMENTS/M-AF-02.DOC