2016-03-16_REPORT - M2012027

• Permit No: M2012027
• IBM Index Class Name: Report
• Doc Date: 3/16/2016
• Doc Name: Annual Fee Notice
• From: DRMS
• To: B & L Cogan, L.L.C.
• Annual Report Year: 2016
• 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 pr int
current contact information:

Permittee Contact:

Laurie Jacobson
Permittee Company:

B & L Cogan, L.L.C.
Address:

24800 US. Hwy 285 S.

Buena Vista, CO 81211

Phone Number:

[phone]
Fax Number:
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 Permittee, Corporate Officer, Owner, or Documented Designee Date

M-AF-01