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L7COLORADO <br />®; Division of Reclamation, <br />Mining and Safety <br />Department of Natural Resources <br />1313 Sherman St. Room 215 <br />Denver, CO 80203 <br />January 2, 2017 , <br />Kane Schneider <br />Colorado Department of Transportation <br />606 S. 9th St. <br />Grand Junction, CO 81501 <br />r E'< <br />JAN 0 4 2017 <br />1�1 <br />vimA 0- y�5 <br />TTL <br />14r44rv- <br />7 0.0 0 5.17 �o B <br />Independence Pass, Permit M-1984-103, Annual Fee Invoice and Report Request <br />PLEASE READ CAREFULLY—ACTION REQUIRED <br />Please attach your COMPLETED written Annual Report and Annual Report Man to this form <br />Under the terms of your Reclamation Permit and Colorado Statutes, you must submit an Annual Fee and <br />Annual Report (including a map). You must pay the Annual Fee and submit an Annual Report each year <br />until reclamation responsibility release is granted. The Annual Fee is not a renewal fee. The Fee and Report <br />are for LAST YEAR'S mining and reclamation season, and MUST be paid even if your operation was <br />inactive. <br />The Annual Report and Fee requirement will be considered submitted when we have received the <br />following components: <br />I. APPROPRIATE ANNUAL FEE <br />2. COMPLETED ANNUAL REPORT <br />3. ASSOCIATED MAP as required by rule <br />If you have requested reclamation responsibility release from the Division of Reclamation, Mining and <br />Safety (the "Division") but your permit is not released by the anniversary date listed below, the Annual Fee <br />MUST be paid. If the permit is released before the anniversary date, then by Statute, it is not necessary to <br />pay an Annual Fee or submit an Annual Report for that year. <br />Division records indicate the $323.00 fee is due for the following: <br />Permit: M-1984-103 <br />Operation Name: Independence Pass <br />Anniversary Date: February 1, 2017 <br />Total Fee Due: $323.00 (Due on or before your Anniversary Date) <br />I hereby certify that I have received the goods or services listed <br />hereon, thet ( have carefully inspected weighed, counted or <br />measured rhe commodities and found them to good condition <br />and corrplying with the specifications given or that the goods <br />and service-,- are in contract compliance, or that the services <br />were satisfactory except as not ��t <br />C— <br />'ibate recieved Signature of Person accepti s/seryloes <br />Patrol # Print Name <br />N <br />Cost Center Obl. — /Sub. Function <br />1313 Sherman St. Room 215 Denver, CO 80203 P (303) 866-3567 F "' , : o' <br />John W. Hickenlooper, Governor I Robert W. Randall, Executive Director i Virginia Brannon, Director <br />