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r X r / <br />A UAL FEE and REPORT REQUEST <br />RECEIVED <br />PERMITTEE NAME: rCoulson Excavating Company, Inc. <br />PERMIT NO.: A- 1985 -026 " 1 N 2 0 2012 <br />OPERATION NAME: Challenger Pit , Division of Reclamation, <br />ANNIVERSARY DATE: January 31, 2012 <br />vir Mining & Safety <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <br />Permittee Contact: Richard Coulson <br />Permittee Name: Coulson Excavating Company, Inc. <br />Address: 3609 North County Road 13 <br />Phone Number: <br />Fax Number: <br />Date <br />Loveland, CO 80538 <br />(970) 667 -2178 <br />(970) 667 -2193 <br />Sig <br />ture of Co orate Officer, Owner, or Designee <br />D ire% ' � ecre <br />J an iana uar y 1 , <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, 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 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 />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 />** **There has been no activity at this mine since 2003. All mining and reclamation <br />have been completed and we are just waiting on final water augmentation to be completed. <br />Request for acceptance for completion will then be made <br />