2015-10-13_REPORT - M1978170

• Permit No: M1978170
• IBM Index Class Name: REPORT
• Doc Date: 10/13/2015
• Doc Name: Annual Fee, Report & Map
• From: Delta County
• To: DRMS
• Email Name: SJM
• 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:
Bob Basher
Permittee Company:
Delta County
Address:
501 Palmer St Ste 227
Delta, CO 81416
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 accordance with the Division approved mining and reclamation plans.
Signature of
M -AF -04
Officer, Owner, aCr Documented Designee
/� / //-1 5 - -
Date