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COLORDO BOARD OF LAND COMMISSIONERS <br />620 Centennial Building <br />1313 Sherman Street, Suite 621 <br />Denver, CO 80203, (303) 866-3772 <br />MINERAL ROYALTY REPORT <br />Lease Type LT GM GL GP QR UR CY PL GE GS DW OS OM (CIRCLE ONE) <br />State Lease No. GP3395. <br />County_Conejoes <br />Lessee_Alamosa County <br />Subsection_SEQTR_Section(s)_4_ <br />Product Pit Run <br />Unit of Measure YD TN LB <br />Beginning Inventory <br />Ending Inventory <br />Selling Price per Unit <br />Royalty Rate 0.30 <br />For Adjusted Reports, Previous Amount Paid $_ <br />(CIRCLE ONE) <br />Units Produced <br />Units Soli <br />Gross Sale <br />ROYALTY DUE $0.00 <br />Advance Minimum Royalty Credit (if applicable) $ <br />ROYALTY PAID$ $0.00 <br />If this is an adjustment, please explain <br />Contact Name^Phil West Telephone No. (719) _589-6262 <br />certify that this is a true and correct statement of production sold, value received, and royalty <br />due the State of Colorado for the period indicated. <br />Authorized Signature & Title <br />Reporting Company Name_Alamosa County Road & Bridge Dept._ Payor Number_701_ <br />Address 8663 S Cnty Rd 109 <br />Alamosa, CO 81101-9423 <br />Subscribed and sworn to before me by <br />On this day of 20 <br />My Commission Expires 20 <br />Notary Public. <br />Date Stamp Land Board Use Only <br />Verfied Receipt No. <br />Posted Date <br />Notes: <br />SL/0702 <br />Original_X Adjustment <br />Production Month & Year SEPTEMBER 2005 <br />Produced/Operated by <br />Town s h i p_36Ra n g e_8_ <br />OZ BL OT <br />