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mAc- <br />or— <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANN e ' 7 <br />LFEE �[nd P T REQUEST <br />oken Arrow Investments, LLC <br />v M- 2008 -017 <br />Derr Pit <br />December 16, 2009 <br />�i <br />$$791.00 (Due on or before your anniversary date) <br />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 map showing the extent of current disturbances to affected land, <br />r _accomplish to da and during the preceding year, new disturbances that ar ant icipated to occur <br />during the upcoming year, reclamation thaf will be performed during the coming year`, the dates for the b "eginning <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 for 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 duriny- the previous year and no new chan to <br />the p revious year's map are necessary, then no new map is required, provided t hat the Operato 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: Darwin Derr <br />Permittee Name: Broken Arrow Investments, LLC <br />Address: 699 N. First Avenue <br />Greeley, CO 80631" <br />Phone Number: (970) 590 -1063 <br />Fax Number: (866) 246 -6973 <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 instructions are enclosed. <br />ignature of Corporate Owner, or Designee <br />Date <br />