2013-12-02_REPORT - P2010003

• Permit No: P2010003
• IBM Index Class Name: Report
• Doc Date: 12/2/2013
• Doc Name: Annual Fee and Report Invoicing January 2014
• From: DRMS
• To: Operator
• Media Type: D
• Archive: No

Page 4 of 4

Division records indicate the following permittee/landowner contact information. If this information is not current, please
type or print current contact information: Rule 5.6.1(a, b).

Permittee Contact:

Jack Clark
Permittee Company:

Jack Clark, Jr.
Address:

P. O. Box 767

Silverton, CO 81433

Phone Number:

[phone]
Fax Number:
Email Address: CF.PR.email

Landowner Contact:

Landowner Address:

Landowner Phone
Number:

Landowner Email

I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in accordance with the Division approved NOI and reclamation plans. Rule 5.6.1(h).

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date