1. 1. License Number        Original Approval Date

2. Name of License Holder
Mailing Address:
Street
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Telephone Number:   Fax Number:

Primary Contact or Agent:
Mailing Address:
Street
City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Zip
Telephone Number:   Fax Number:

3. The time period covered by this Annual Report is one year, based upon the original approval date. This Annual Report covers (month, day, year)    to

4. On a separate sheet, briefly describe the testing/mining conducted during this Annual Report period. Please describe all deviations from the procedures approved in the License and/or deviations from predictions made in previous Annual Reports. Include the amount of groundwater (in gallons) affected, acres affected during the period and to date.

5. On a separate sheet, briefly describe the progress of all reclamation since original License approval. Please describe all deviation from approved License procedures and/or deviations from predictions made in previous Annual Reports.

6. On a clear map (or aerial photograph), please show the location of all testing/mining activities and all reclamation activities. The map should have complete legend information including: north arrow, section number, township number, range number, county, and scale.

7. On a separate sheet, please provide a reclamation bond estimate which itemized the License Holder's expected costs for reclaiming:

A. all lands which were disturbed since License approval and which have not been released in writing by the DEQ/LQD.

B. all lands which will be disturbed during the next Annual Report period.

C. all groundwater affected by research activities.

8. If License renewal is not requested, you must initiate and complete permanent, final reclamation of all disturbed lands according to approved License provisions. Final termination of reclamation liability and reclamation bond release will not occur until the surface owner and DEQ/LQD jointly determine that reclamation is complete and revegetation is successful.

9. The Licensee wishes to renew this License.      Yes       No

10. Printed name of person preparing this Annual Report: