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~~ ~ ~ ~s~- ~~ 06 ~-oh ~/ ANNUAL FEE and REPORT RE_ VEST PERMITTEENAME: / CoulsonExcavatingCompany ~~~~~,~~~~® PERMIT NO.: ~M-1979-059 /~~~ 3 '~ 2~~5 OPERATION NAME: Brownwood Pit ~f~isian Qy ~~~rion, ~~''~ `mod ~~ ANNNERSARY DATE: November 20, 2006 ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) COUNTY: Latimer According to C.R.S~34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator ` ~ I shall submit [he annual fee, a report and map showing the extent of current disturbances to affected land, during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach vour revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous vear and no new chances to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may since for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Richard Coulson Permittee Name: Coulson Excavating Company Address: 3609 N. CR 13 Loveland, CO 80538 Phone Number: (970) 667-2178 Fax Number: (970) 667-2193 If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. ~^-~, Sic. Signature of Corpo t2d e OfI'lcer, Owner, or Designee Dct ~'7 ~lQ Date