2017-02-22_REPORT - M1996089

• Permit No: M1996089
• IBM Index Class Name: REPORT
• Doc Date: 2/22/2017
• Doc Name: Annual Fee/Report/Map
• From: Skoglund Excavating
• To: DRMS
• Annual Report Year: 2017
• Email Name: SJM
• 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: Kenneth L.Skoglund
Permittee Company: Skoglund Excavating Inc.
Address: I Ith and Broadway
P.O.Box 209
Moffat,CO 81143
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Kenneth L. Skoglund
Company: Skoglund Excavating Inc.
Address: 1 lth and Broadway
Moffat, CO 81134
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact: Kenneth L. Skoglund
Company: Skoglund Excavating Inc.
Address: 1 Ith and Broadway
Moffat,CO 81134
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
I,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,Coraorate Officer,Owner,or Documented Designee Date
M-AF-01