2016-11-16_M2003070_Annual Fee Notice ARCHIVE

• Permit No: M2003070A
• IBM Index Class Name: Report
• Doc Date: 11/16/2016
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Baca County
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

Page 5 of 5

Division records indicate the following permittee/landowner contact information (blank fields indicate that we do not have
information on record). If this information is blank or not current , please type or print current contact information:
Permittee Contact:

Peter L. Dawson
Permittee Company:

Baca County
Address:

741 Main St.,Suite 1
Springfield, CO 81073

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Permitting Contact:

Peter L. Dawson
Company:

Baca County
Address:

741 Main St.
Springfield, CO 81073

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Inspection Contact:

Peter L. Dawson
Company:

Baca County District 2
Address:

121 W. 1st.
Campo, CO 81090

Phone Number:

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

M-AF-04