2015-08-25_REPORT - M1977081

• Permit No: M1977081
• IBM Index Class Name: REPORT
• Doc Date: 8/25/2015
• Doc Name: Annual Fee, Report & Map
• From: City of Greeley
• To: DRMS
• Email Name: PSH
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following pennittee contact information. If this information is not current. please type or
print current contact infonmation:
Permittee Contact:
Jim Nall
Christie Coleman
Penmittee Company:
City of Greeley
Address:
1100 10th Street, Suite 300
Greeley, CO 80631
Phone Number:
(303) 3364039
[phone]
fax Number:
Email Address:
1, 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 mining and reclamation plans.
S- Z!- LS
Signature of Permittee. Corporate Officer, Owner, or Documented Designee Date