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• LK �1559'1 �G88 % <br /> III IIIIIIIIIIIIIIII <br /> 999 <br /> ANNUAL FEE and REPORT REQUEST <br /> PERMITTEE NAME: Coulson Excavating Co.,Inc. ` <br /> PERMIT NO.: <br /> � g � <br /> OPERATION NAME: Challenger Pit <br /> !v!sion <br /> ANNIVERSARY DATE: January 31,2001 ivision��Oiner 'san 500 <br /> �,, <br /> inerals and To$�, <br /> ANNUAL FEE DUE: $688.00(Due on or before your anniversary date) 8Y <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 d e of the permit, an <br /> operator shall submit the annual fee, a report and map showing the extent of current disc rances to affected <br /> b <br /> land, reclamation accomplished to date and during the preceding year, new disturbances t at are anticipated to <br /> occur during the upcoming year, reclamation that will be performed during the coming y ar, the dates for the <br /> beginning 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. Please note that all <br /> adequately labeled map that clearly delineates and includes the above elements may .�riffice for a ivriuen <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and �iake any necessary <br /> changes: <br /> Permittee Contact: Richard Coulson <br /> Permittee Name: Coulson Excavating Co., Inc. <br /> Address: 3609 N. CR 13 <br /> Loveland, CO 80538 <br /> Phone Number: (970) 667-2178 <br /> Fax Number: (970) 667-2193 <br /> If you have additional comments and/or information that should be provided to the Divisi n, please provide it <br /> below or attach it to this form along with your written report and map. Annual Re ort instructions are <br /> enclosed. <br /> I <br /> Signature of Corporate^ fficer r Owner <br /> t\tip �•pn�•L.it 1 5� 2000 <br /> Date <br /> M SPERM IT\MASTERDOCU M ENTSN7-AF-U I <br />