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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 ermit, an <br />—operator-shall-submit-the-annual-fee, -a-re - and , 2 - slowing -the -e .tent4rturreti f rtan -LNO of ected <br />land /reclamation accomplished to date and during the preceding year new disturbances that are anticipated to <br />occur during the upcoming yeah, reclamation amation that will be performed dturing the coming year, the dates for the <br />beginning of active operations, and the date . . ' �- e , , 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 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 C. Harden <br />7176.PN e. 14 ?i no ftA <br />Permittee Name: Joseph Curtis Harden <br />Address: P.O. Box 1207 <br />Phone Number: <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 />ignature of Corporate O Icer, Owner, or Designee <br />10 -( • Zoll <br />Date <br />M:( PERMITIMASTERDOCUMENTS/M- AF -02. DOC <br />Idaho Springs, CO 80452 <br />(303) 567 -2259 <br />ANN[IAL FEE and REP RT REQUEST <br />1 <br />Joseph Curtis Harden or heoiamation, <br />tv / M- 2004 -008 Mining and S a t Edy <br />V The Mountain Mining Claim <br />October 28, 2011 <br />$$259.00 (Due on or before your anniversary date) <br />Clear Creek <br />Tottt Z. I ARRse#.ry <br />P. 0. 1207 <br />ZiAyo fpAiF.f•/ G .4. B b'i S'Z <br />(10,) 567- 1.% s9 <br />/V /4 <br />OCR 21 20)1 <br />