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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />AG Alpha No. NR LR HVWG <br />AG File No. DNR/6988 /LW <br />M Mun'sharelhondforms`,fee agreement self assurance doc <br />(05/27/2004) <br />Office of <br />RECEIVED <br />FEB 0 4 2013 <br />DIVISION OF RECLAMATION <br />UMW AND SAFETY <br />Fee Agreement for Self- Assurance <br />STATE OF COLORADO <br />The undersigned, pursuant to C.R.S. 1973, 34- 32- 122(2), as amended, and pursuant to Rule 7.5(f)(1)(2)(3)(4) of the <br />Rules and Regulations of the Colorado Mined Land Reclamation Board for Minerals (Non -Coal) Mining, hereby <br />agrees to be responsible for the actual costs of establishing and reviewing the undersigned's Financial Warranty. The <br />undersigned further understands and agrees that these costs include the initial costs of establishing the Financial <br />Warranty, and also the annual costs of reviewing the Financial Warranty. <br />The undersigned understands and agrees that he shall be responsible for all applicable costs assessed hereunder in an <br />amount and form to be determined by the Board pursuant to C.R.S. 1973, 34- 32- 122(2), whether or not the Board <br />issues the permit. <br />The undersigned agrees to pay these fees upon presentation of a bill from the Division of Reclamation, Mining and <br />Safety. nn � � + <br />, d° 7)-1- ro �?a�l a yeoriz t L P <br />COLORADO <br />D I V I S I O N O F <br />RECLAMATION <br />MINING <br />SAFETY <br />w :J , -L4 I . e r) i <br />Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and Inactive Mines <br />