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ANNUAL FEE an REPORT QUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />?L loff Construction, Inc. <br />UM-1985-112 <br />Loloff Mine <br />February 4, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <br />0 <br />MAR 18 2010 <br />IviiEi®n of Reclamation, <br />ji4tMing and safety` <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 />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 may 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 />Phone Number: <br />Fax Number: <br />Kersey, CO 80644 <br />(970) 353-1621 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach irto this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corporate Officer" mer, or Designee <br />1 - /' ?-- <br />Date <br />_ t e 4 -e--- -- -- n:: -- - --- - -- p ty c--- t - - -- - - - f ! !