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g EL <br />PERMITTEE NAME: 1 Ja�c k Pine Mining Company ,/ <br />PERMIT NO.: - 1990 -147 <br />OPERATION NAME: Mendota Properties <br />ANNIVERSARY DATE: February 12, 2012 <br />ANNUAL FEE DUE: $$259.00 (Due on or before your anniversary date) <br />COUNTY: Clear Creek <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 niap 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. 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: Fabyan Watrous <br />Permittee Name: Jack Pine Mining Company <br />Address: P.O. Box 66 <br />Idaho Springs, CO 80452 -0066 <br />Phone Number: (303) 567 -2350 <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 />// 9 <br />! 4 4J&G / <br />Signature of Coi orate Officer, 0 or- Designee <br />Date <br />M \PERMIT \MASTERDOCUMENTS /M -AF -02 DOC <br />AN f L FEE and REPORT REQUEST <br />/Y"0 ‘• fete. <br />c Dlrt .1 s1 ,,I i, . •, :r .f410n, <br />� <br />. G; -Z /i/ a'1E4 -- = <br />{uED <br />e., L. S�xc�1 <br />RECEIVED <br />JAN 2 0 2012 <br />Division of Reclamation, <br />Mining & Safety <br />