2015-09-09_REPORT - M2002106

• Permit No: M2002106
• IBM Index Class Name: REPORT
• Doc Date: 9/9/2015
• Doc Name: Annual Fee, Report & Map
• From: Larry Mondragon
• To: DRMS
• Email Name: WHE
• 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:
LarryMondragon
Permittee Company:
Larry Mondragon
Address:
9451 U.S. Hwy. 285 S
Alamosa, C081 101
Phone Number:
[phone]
Fax Number:
Email Address:
I, 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.
Signature
M -AF -01
Owner, or Documented Designee
�11s
Date