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ANNUAL FEE and R PORT REQUEST <br />PERMITTEE NAME: N en Arrow Investments, LLC ' y2 <br />? <br />,^ <br />PERMIT NO.: 7M-2,008-017 <br />OPERATION NAME: Derr Pit / V <br />ANNIVERSARY DATE: December 16, 2010 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <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 />- --rcclamation-a. comglhzdoate arid?urm`g?he 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 vear's man are necessarv. 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: Darwin Derr <br />Permittee Name: Broken Arrow Investments, LLC <br />Address: 699 N. First Avenue <br />Greeley, CO 80631 <br />Phone Number: (970) 590-1063 <br />Fax Number: (866) 246-6973 <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 />d ?_? <br />ignature of Corpora e O icer, owner, or Designee <br />- ?- 0 t1) <br />,?( U/0 <br />Date