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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />TGl+la111a1.1v11 dl,Y.l33 MAJ. _ I.v t�Q.w claw. W. ' Lll 1L vulli 11\i U. 3 i ' i ' : _ - 1, • : 1 ivi r � cif - cif Viii. u� <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Daniel L. Collins <br />Permittee Name: <br />Address: <br />B - Mining Company <br />1417 S. Grandview Dr. <br />Tempe, AZ 85281 <br />Phone Number: (480) 894 -6211 <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 enclosed. <br />ignature of Corporate Officer, Owner, or Designee <br />Date <br />ANNAEFEE and REPORT REQUEST <br />B - Mining Company <br />LAI- 1986 -102 <br />Deep Creek Placer <br />September 4, 2011 <br />$323.00 (Due on or before your anniversary date) <br />San Miguel <br />RECE <br />`.IFS OR 7n11 <br />Division of Reclamation, <br />ko Mining and Safety <br />