2015-07-24_REPORT - M2004036

• Permit No: M2004036
• IBM Index Class Name: Report
• Doc Date: 7/24/2015
• Doc Name: Annual Fee/Report/Map
• From: Mason King
• To: DRMS
• Annual Report Year: 2015
• Email Name: ERR
• Media Type: D
• Archive: No

Page 5 of b
Division records indicate the following permittee contact information. If this information is not current, please type or
print current contact information:
Permittee Contact:
Mason A. King
Permittee Company:
Mason King
Address:
P.O. Box 68
Cope, CO 80812
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
I, the undersigned, hereby state that th nformation provided in this report is true and accurate, and that site operations are
being conducted in accordance withDivision approved mining and reclamation plans.
Signature of
M -AF -01
O-*Nner, or Documented Designee
Date