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~ ~- ~ RPM' <br />ANNUAL FEE and REPORT REQUEST <br />PERMTTTEE NAME: Loloff Construction, Inc. ~ ~~(°~'~~® <br />PERMIT NO.: M-1985-112 ~/ ,SAN 2 L Zod~ / <br />OPERATION NAME: Loloff Mine Division or rteclamation, <br />ANNIVERSARY DATE: February 4, 2008 Mining and Safety <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <br />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 operator <br />------shall-submit the-annual-fee,-a-report-and :nap-showing-the. extent .of-correr_± d2sfiarbances ±o--affected. lar_d,- <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's man are necessary. then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Don Loloff <br />Permittee Name: Loloff Construction, Inc. <br />Address: P.O. Box 518 <br />- - 206 Hill St. - ~ - - - <br />Kersey, CO 80644 <br />i <br />Phone Number: (970) 353-1621 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below o~ttach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Owner, or Designee <br />