2015-08-06_REPORT - P2011004

• Permit No: P2011004
• IBM Index Class Name: Report
• Doc Date: 8/6/2015
• Doc Name: Annual Fee, Report and Map
• From: Sara Ray Silver Mining LLC
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

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:
DaleHerbertson
Permittee Company:
Sara Ray Silver Mining LLC
Address:
6542 W. Mexico Ave.
Lakewood, C080232
Phone Number:
[phone]
Fax Number:
Email Address:
[e-mail]
Landowner Contact:
Landowner Address:
Landowner Phone
Number:
Landowner Email
I, the and, hereby state that the information provided in this report is true and accurate, and that site operations are
being nducted accordance with the Divjsion approved NOI and reclamation plans. Rule 5.6.1(h).
Signature ofPermittee, Corporate Officer, Owner, or Documented Designee
P -AF -01
Date