2016-12-08_REPORT - M1985026

• Permit No: M1985026
• IBM Index Class Name: REPORT
• Doc Date: 12/8/2016
• Doc Name: Annual Fee/Report/Map
• From: Coulson Excavating Company, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have
information on record). If this information is blank or not current,please type or print current contact information:
Permittee Contact: Richard Coulson
Permittee Company: Coulson Excavating Company,
Inc.
Address: 3609 North County Road 13
Loveland, CO 80538
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact: Richard Coulson
Company: Coulson Excavating Company,
Inc.
Address: 3609 North County Road 13
Loveland, CO 80538
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
1,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
Signature of-Permittee, Cor or to COcer,Owner,or 6ocumented Designee Date
M-AF-01