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� J <br />ANN AL FEE and REPORT REQUEST <br />PERMITTEE NAME: F9alfrumwurkin, LLLP <br />PERMIT NO.: vM -2004 -047 <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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_ anddurin$ 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 map 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: Jon File <br />Permittee Name: <br />Address: <br />Farfrumwurkin, LLLP <br />P.O. Box 983 <br />Broomfield, CO — 80038 <br />Phone umber: (303) 404 -3225 <br />Fax Number: (303) 404 -0778 <br />Signat re o Corporate Officer, Owner, or Designee <br />r 2k)--/// <br />Date <br />A EC( AVER <br />4.1 ALin2 2011 <br />i�lvi io� ion, <br />File Pit 112 ID Mining and $afoul <br />August 4, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <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 />740-- <br />