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Nv k R? T <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Skoglund Excavating Inc. t* <br />PERMIT NO.: M-1996-089 <br />OPERATION NAME: Skoglund Pit <br />ANNIVERSARY DATE: March 20, 2009 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Saguache <br />:;... , y <br />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 <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 />=--- -during the-upcoming year,?aa?ronhawill-be performed-drirrg-the eerning?*earhe dates-fo <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report may 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 during the previous year and no new chances 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: Kenneth L. Skoglund <br />Permittee Name: Skoglund Excavating Inc. <br />Address: 11th and Broadway <br />P.O. BOX 209 <br />Moffat, CO 81143 <br />Phone Number: (719) 256-4447 ??ll Am L' - 711 ° U Y - .27.3& 2 <br />Fax Number: (719) 256-4447 ('rvu,' j'/ - rnorys8-oll cUjajoo.foAn <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 />L <br />Signature of Corporate Officer, Owner, o Designee <br />3/?/a 9 <br />Date