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15 DPT AS State of Colorado <br />FORM DS-648 79-09 EARTH OR STONE PRODUCTS REAL AND PERSONAL <br />PROPERTY DECLARATION SCHEDULE <br />(CONFIDEWFIAL DA I A) Assessment Date Due Date <br />January 1, April 15, <br />Washington _ County RETURN TO COUNTY ASSESSOR 2009 2009 <br />B A CODE T A. CODE= SCHEDULE NtiMR R DO NOT ISE - FOR ASSESSOR ONLY <br />5120 411 1911-G Code Description :acres Toac Actual % Assessed <br /> Vatic Valk <br />A. NAME AND ADDRESS Earth of Stm e <br />INDICATE ANY CHANGES/CORRECTIONS SI20 Product• $ 29% S <br />) <br />( <br />SPRAGUE SCRAPER SERVICE INC <br />$ JEFFREY SPRAGUE <br /> 5220 Im rovemeats S 29% S <br />610 ELLIS AVENUE <br />WRAY CO 80758-0758 <br /> Nu+p.. Fum. & <br />PHYSICAL LOCATION/LEGAL DESCRIPTION OF THE Sato Marhmen S 29% S <br />PROPERTY AS OF JANUARY 1, 2009: <br />SPRAGUE PIT SWSW 25 5N 49 TOTALS 3 S <br />GRAVEL PIT SWSW 25 5N 49 RECEIVED APPROVED <br />PERMIT # M2005032 COMPLETED ABSTRACTCHGS. <br /> LATE FILING PIiNAi I Y ? YES 0 NO <br /> APPLIED <br /> <br />I If you are not the current fussiness owner please list the name <br />K OPERATION: Start-up Date <br />and addrum of the new owner below. <br />! Date Sold <br />Type of Product - - t <br />??Clay?_ e?_ I <br />BUSINESS ? NEW 11 NEW <br />STATUS: (Check the Appropriate Box) BUSINESS OWNER(S) <br />? Check this box if this is your first return. <br />If this, is our fast return, You MUST furnish a complete itemized listing. <br />C. PRODUCTION <br />List the description. voitnne, royalty rate, and retail sale rice of an earth or stone extracted during the preceding calendar year. <br />TYPE OF PRODUCT EXTRACTED ` TONS ROYALTY CUBIC YARDS ROYALTY WEIGHTED AVERAGE <br /> EXTRACTED PER TON EXTRACTED PER Cl4YD. RETAIL SALE PRICE/t1NIT <br />A• 120o1d Jd,ZS? _ 52 y vo s <br /> <br />C. $ <br />D. $ $ <br />D. LEASE AND PERMIT INFORMATION Attach a co ' of the lease. <br />NAME OF LESSOR I DATE OF LEASE <br />LENGTH OF LEASE: <br />LEASE OPTIONS DMG PERMIT NUMBER <br />E. LAND INFORMATION <br />PERMITTED ACRES ?, AFFECTED ACRES <br />FSfIMA r ED <br />F_ LISTING OF REAL PROPERTY IMPROVEMFNTS (attach senur9te ehpr+tral_ if noommearvl <br />1 YEARS i <br />List buildings and other improvements constructed or installed the previous year. Include the property description and installation <br />date, our original installed cost, and an additions since on inaI installation. <br />Buildings and Other Improvements Descriptions and IA"tion <br />_ Date Of Yewr OrEgioat Additives Sieve Original <br />Installation <br />Installed (lost IestaHative <br /> _ <br /> <br /> <br />SEE OTHER SIDE