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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Coulson Excavating Company <br />M-1979-059 <br />Brownwood Pit <br />November 20, 2002 <br />RECEIVED <br />OCT i 8 ~ <br />~tvision of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Larimer <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 mao to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate [he following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Richard Coulson <br />Permittee Name: Coulson Excavating Company <br />Address: 3609 N. CR 13 <br />Loveland, CO 80538 <br />Phone Number: (970) 667-2178 <br />Fax Number: (970) 667-2193 <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 />I10; n,..,L t , ~ <br />Signature of Corpo ate Of 'cer, Owner, or Designee <br />4~bb~ t5 ~ 'aLb~ <br />Date <br /> <br />M: W ERMITUTASTERDOCUMENTSVN-AF-01 <br />