2016-11-16_REPORT - M2005012

• Permit No: M2005012
• IBM Index Class Name: Report
• Doc Date: 11/16/2016
• From: DRMS
• To: Nick H. Gray
• Annual Report Year: 2017
• Media Type: D
• Archive: No

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:

Nick H. Gray
Permittee Company:

Nick H. Gray
Address:

584 65.30 Rd.
Montrose, CO 81401

Phone Number:

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

Timothy M. Scanlon
Company:

TMS Consulting
Address:

46125 County Road T
P.O. Box 53
Saguache, CO 81149

Phone Number:

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

Nick H. Gray
Company:

Nick H. Gray
Address:

584 65.30 Rd.
Montrose, CO 81401

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 Permittee, Corporate Officer, Owner, or Documented Designee Date
M-AF-01