2015-08-21_REPORT - M1984136

• Permit No: M1984136
• IBM Index Class Name: REPORT
• Doc Date: 8/21/2015
• Doc Name: Annual Fee, Report & Map
• From: Prowers County
• To: DRMS
• Email Name: AME
• 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:
Mark Dorenkamp
Permittee Company:
Prowers County
Address:
109 E. Sherman St.
Lamar, CO 81052
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being condu ted in accordance wM the Divi siq apgrov d mining and reclamation plans.
Signature of
M -AF -04
Owner, or Documented Designee
Date