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4P + Q6-' <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />C? <br />'. 7westley Potts <br />,/M-1983-030 <br />Twin Canyon Mine <br />June 10, 2010 <br />$86.00 (Due on or before your anniversary date) <br />Montezuma <br /> <br />Mision of Reclamailon, <br />iafting St Safefil <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 <br />operator shahs- uGm`it the annual"fee, -a repo- and map sh6wmg the e-xTennfof current disturbances to-affect-d- ?- - <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous vear's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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: James Potts <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <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 <br />enclosed. <br />Signatur of Corporate Officer, Owner, or Designee <br />- 04621 J2 26 In <br />Date <br />Westley Potts <br />41375 Road H <br />Mancos, CO 81328 <br />(970) 533-7106 <br />M:IPERNEMIASTERDOCUMENTS/M-AF-02. DOC