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AF *- asr <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: f Skoglund Excavating Inc. COVE <br />PERMIT NO.: M-1996-089 V MAR 2 2 ZU <br />OPERATION NAME: Skoglund Pit •?/ Division of Mining Reclamation, <br />.Y & Safety <br />ANNIVERSARY DATE: March 20, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Saguache <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, -recfamatiori that will be performed -during-the coming year, the dates for the beginning <br />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. 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 changes to <br />the previous year's may 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 since 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 <br />Fax Number: (719) 256-4447 <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 Corporate Officer, Owner, or Designee <br />S o -- c? <br />Date