2016-10-11_REPORT - M1999083 ‎(2)‎

• Permit No: M1999083
• IBM Index Class Name: Report
• Doc Date: 10/11/2016
• Doc Name: Annual Fee/Report/Map
• From: Rother Pit No. 1
• To: DRMS
• Annual Report Year: 2016
• Email Name: ERR
• 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:
Marcy Brossman
Permittee Company:
Cheyenne County
Address:
P.O. Box 567
Cheyenne Wells, CO 80810
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
rr•,F-as
County Administrator
Owner, or Documented Designee
9-19-16
Date