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<br />~~ ~ Q~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Coulson Excavating Company, Inc. <br />M-2005-033 / <br />Gardels Pit <br />October 6, 2007 <br />RECEDED <br />2p200~ / <br />SEP <br />~amauon. <br />ion of R d Sa{et`I <br />~~~~m9 an <br />$$791.00 (Due on or before your anniversary date) <br />Lorimer <br />_ According to_C.R.S. 34-32.5-116 or_C.R.S. 34-32-1.16, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />- - -- .. <br />during fhe upcoming year, reclamation that will 6e perfoimed "during the coming year; the dates for the lieginriing <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach our revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durinti the previous vear and no new chanties to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Richard Coulson <br />Permittee Name: Coulson Excavating Company, 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 Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corpora e Offi er, Owner, or esignee <br />Sfa~Yn,Joss- i`j, a,bb2 <br />Data <br />