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vie, <br />,' /(? r- 412-- <br />ANN ffAFEE and REPORT REQUEST <br />PERMITTEE NAME: X-:2002-003 cier Peak Art, Gems & Minerals RECEIVED <br />PERMIT NO.: `'MAR 0 8 2011 <br />OPERATION NAME: Topaz Mt. Gem Mine Division of Reclamatlon, <br />11p Mining & Safely <br />ANNIVERSARY DATE: March 26, 2011 <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 />-- -. <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 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 changes to the Drevious vear's maD are necessarv, then no new man is reauired, 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 />4L?'Z' <br />Sig a{ure o Corporate Officer, Owner, or Designee <br />Date <br />M: \PERMITIMASTERDOCUMENTS/M-AF-02. DOC <br />