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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />James VanElla <br />M- 1992 -045 <br />Gold Basin Mine 402 <br />26, 2011 <br />$259.00 (Due on or before your anniversary date) <br />Chaffee <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.curr t turbances to affec_e <br />'land, - re 1 fiiation 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 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 />Phone Number: (260) 255 -9010 <br />• <br />•i <br />•I <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. \ I <br />ignature of Corporate Officer, Owne or Designee <br />55- <br />Date <br />M:\ PERMIT \MASTERDOCUMENTS /M- AF- 02.DOC <br />P• 4°.• <br />D EC 0 32011 <br />mining .rt(),af,l/ <br />..--.. P. re. Pm Q, <br />DEC 032011 <br />. jmatlOil, <br />...,,.., aff et j <br />