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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />v DGMC RECEI <br />.//M-1986-076 CFn 1 2Q1, <br />Incas Mine Division of kedamation, <br />December 31, 2010 Mining and Safb#y <br />$518.00 (Due on or before your anniversary date) <br />La Plata <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />-- operator-shall_submit-the-annual-fee,_a report-and map-showing the extent-of-current distur-banes-to.affected_-__ _ <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report may to this form The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's map are necessary, then no new may is required provided that the <br />Operator shall state this in the Annual Report Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: 4im-$enE <br />? A kA,- A t Y..' <br />Permittee Name: -- )GW cS A ? t ?, 0- 00 r <br />Address: S-FAHVmTjx-6 4 <br />/ aZ S' Ltj <br />Farmington, NM 87401 <br />Phone Number: (5 5 'S0 s- - 3 9 <br />Fax Number: (505) 38rS0 S-off S-? y _ Z3 <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 />ose . <br />Signature of Corporate Officer, Owner, or Designee <br />l _ e3?`r .?old <br />e <br />,at <br />V re otv.veys?.p -0 /- 3--ZC) T rv? 1<?o?vfee?'eJ <br />? y "- <br />MAPERNflrMASTERDOCUMENTS1M AF-02.DOC A/,p ? <br />, R. 11 wae.s dew ?x 1 rv-/e .v a. .v a <br />I