OHIO DEPARTMENT OF NATURAL RESOURCES

							                                   Ohio Department of Natural Resources
                                  Division of Mineral Resources Management
                           2045 Morse Road, Bldg. H-3, Columbus, OH 43229-6693
                                 (Prepare 3 copies with original signatures)

                          Surface Mining (IM) Annual Report
                       File within thirty (30) days after each anniversary date of issuance
                                             of a Surface Mining Permit

Operator:

Address:

Permit Number:                                       Date Permit Issued:

Permit Year:                     Reporting From:                             To:

Total acres that were estimated to be affected for reporting year:

Total acres affected under permit to date (cumulative total):

     Mining            Acres Affected          Acres Estimated to
                                                                                   Report of Total Tonnage
     Area #           to be Reclaimed         be Affected Next Year

                                                                             Coal:
                                                                             Clay:
                                                                             Shale:
                                                                             Sand/Gravel:
                                                                             Limestone:
                                                                             Sandstone:
                                                                             Other:(        )
   TOTAL                                                                     Total Production:

I, the undersigned, certify that the foregoing information is true and correct.

            Authorized Signature                                     Title                             Date

Tax ID # or Social Security #:




FOR DIVISION USE ONLY:

Report checked and verified by:                                      Date                       ,2

Filing Fee:  $
Acreage Fee: $
Total Fees Due:       $                              Bond Due: $                     for Permit Year


Revised 09/06
DNR-744-6008