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� Illlillilllllilllll � <br /> 999 <br /> ANNUAL FEE and REPORT REQUEST RECEIN' v <br /> APR <br /> PERMITTEE NAME: John O Buckner <br /> PERMIT NO.: M-1993-030 Division of Maerals z4ologY <br /> OPERATION NAME: Crystaljack Mine <br /> ANNIVERSARY DATE: April26,2001 <br /> ANNUAL FEE DUE: $75.00(Due on or before your anniversary date) <br /> COUNTY: Teller <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 your revised written annual report and annual report map to this form. Please note that an <br /> adequately labeled map that clearly delineates and includes the above elements "toy since for a written <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and snake any necessary <br /> changes: <br /> Permittee Contact: John O. Buckner <br /> Permittee Name: John O Buckner <br /> Address: 2516 Waldean St. <br /> Colorado Springs,CO 80909-4015 <br /> Phone Number: (719)634-4042 <br /> Fax Number: (719) 634-5431 <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 /> \' Si nat o o to Officer or Owner <br /> Z; 12e, <br /> Date <br /> M TERMI-DMASTERDOCUMENTSlM-Ar-02.DOC <br />