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.~c.~.tii~"`~ PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNNERSARY DATE: ANNUAL FEE DUE: COUNTY: ANNUAL FEE and REPORT REQUEST Lincoln County M-2006-050 Andersen Farms September 7, 2007 RECEIVED NOV 12 2007 Division of Reclamation, Mining and Safety $$323.00 (Due on or before your anniversary date) Lincoln 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 Dneratnr shall submit the annual fee, a report and map showing the extent of current disturbances to affected occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated man. If no new disturbances or reclamation have occurred during the previous year and no new changes to the urevious year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffrce for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Permittee Name: Address: Don Blake (R~~'. r c ~ Lincoln County P O Box 39 Phone Number: Fax Number: (719)743-2337 (719)743-2815 If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. 7ip~wv.l~6FJ Si ature of Corporate Officer, Owner, or Designee 1~,~6ku ~-~ (~ , 2 ~o~ Date M:~PEAMITJv1ASTERD000M EMS~h1-AF-04