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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Pitkin Iron Corporation <br />M-1982-121 <br />Mid-Continent LST <br />Apri125, 2006 <br />$688.00 (Due on or before your anniversary date) <br />Garfield <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 aze anticipated to <br />occur during the upcoming yeaz, 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 yeaz, if any. <br />Please attach your revised written annual report and annual report mau to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Diane Delaney <br />Permittee Name: Pitkin Iron Corporation <br />Address: 1317 Grand Avenue, Suite 228 <br />P.O. Box 2115 <br />Glenwood Springs, CO 81602 <br />Phone Number: (970) 945-7148 <br />Fax Number: (970) 945-2303 <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 instmctions are enclosed. <br />Signature of Corporate Officer or Owner <br />Date <br />