2015-07-30_REPORT - M1978221

• Permit No: M1978221
• IBM Index Class Name: REPORT
• Doc Date: 7/30/2015
• Doc Name: Annual Fee, Report & Map
• From: #17 Enterprises
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee contact information. If this information is not current, please type or
print current contact information:
Permittee Contact:
Scott stem "-+e-VvaV -
Permittee Company:
#17 Enterprises, LLC
Address:
0275 CR 22
P.O. Box 88
DeBeque, CO 81630
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in acco ce with the Division approved mining and reclamation plans.
Signature of Permittee, Corporate Officer, Owner, or Documented Designee
M -AF -01
Date