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ANNUALE and REPORT REQUEST <br />PERMTFTEE NAME: / Farfrumwurkin, LLLP <br />PERMIT NO.: ~ M-2004-047 <br />OPERATION NAME: File Pit 112 <br />ANNIVERSARY DATE: August 4, 2007 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <br />~ ~C <br />RE~~~~~~t'~ <br />• AUG 0 G 2007 <br />Div~ion of kec~amation, <br />Mining and Safety <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 attach your revised written annual renort 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 mau. If no new disturbances or reclamation have occurred durinc the previous year and no <br />new chances to the previous year'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 since 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 ~ ~ ~t ~e <br />PermitteeName: Farfrumwurkin,LLLP F~12~RuM wuiQ KlK/ LLL~ <br />Address: 11630akhurstDr. PD (joa( 983 <br />P.O. Box 983 Q room -{)?/c/ ~' O 8 ao 3 8 <br />Broomfield, CO 80038 <br />Phone Number: (303) 404-3225 <br />Fax Number: (303) 404-0778 <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 />enc] <br />Signatur of Corporate Officer, Owner, or Designee <br />~ ~1v/o ~ <br />Date ~ <br />M:~PERMITMASTERD000MENCSNr-AF-04 <br />