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&V * UT <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Y Skoglund Excavating Inc. RECEIVED <br />PERMIT NO.: ,/M-1996-089 <br />OPERATION NAME: Skoglund Pit ? MAR 0 7 z U 11 <br />ANNIVERSARY DATE: March 20, 2011 Division of Reclamation, <br />Mining & Safety <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 />_ d g th <br />urine upcoming year, reclamation 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 vear's map are necessarv. then no new map is reauired. Drovided 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: <br />(719) 256-4447 <br />Fax Number: <br />(719) 256-4447 <br />re II -7tq 5?_ a31? 7 <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 />Signatur of orporate Officer, ner, or esignee <br />9- 7-11 <br />Date