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2011 -10 -31 05:05 DRMS <br />PERMITTEE NAME: <br />PERMIT NO.: <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <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 attachyour revised written annual report anal annual report may to this form The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, aril <br />associated map. If nRpew distyrbances or aslamation have e„tnrr unng the Previous year and no <br />new : n es t , revlous ar's m = nec .. the � ew mar , ui . d ro that e <br />for shall to this i Annu rt 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: Tom L. Adams <br />Permittee Name: Exxon Mobil Corporation <br />Address: P.O. Box 2567 <br />Houston, TX 745-2-2-56-7— <br />Phone Number: (281) 654 -6246 <br />Fax Number: (281) 654 -6392 <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 />— 4 <br />Signature of Corporate Officer, Owner, or Designee <br />(1(T((1 <br />Date <br />M;PeOanMnsreRD000t 'rsmA- np- ox.00c <br />3038328106 » 281 654 6392 P 3/5 <br />kc <br />ANNUAL FEE and RF,PQRT REQUEST <br />Exxon Mobil Corporation <br />/ <br />M-1980-04/ <br />Colony Shale Oil Project <br />November 1, 2011 <br />8791.00 (Due on or before your anniversary date) <br />Garfield <br />RECENM <br />NOV 10 2011 <br />Diviaion of ilea, <br />Mining and <br />1 G &.,� Nor f(kc s€- <br />5 2_0O <br />Octi&Si - o-v - Tl- 7 7 0 6 0 <br />