2017-10-23_REPORT - M1979059

• Permit No: M1979059
• IBM Index Class Name: REPORT
• Doc Date: 10/23/2017
• Doc Name: Annual Fee/Report/Map
• From: Coulson Excavating
• To: DRMS
• Annual Report Year: 2017
• Email Name: JLE
• Media Type: D
• Archive: No

Paee 5 of3
-Mvision records indicate the following permittee7landowner contact information(blank Fields indicate that we do not-have
information on record). If this information is blank or not current,}Tease type or print current contact informatiow
i
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: 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]
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]
I,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in acco ance 'vision roved mining and reclamation plans.
0
Signat re Perm ttee, orporate Officer,Owner,or Documented Designee Date
M-AF-01