2016-11-17_REPORT - M1977387

• Permit No: M1977387
• IBM Index Class Name: REPORT
• Doc Date: 11/17/2016
• Doc Name: Annual Fee/Report/Map
• From: Bates Pit
• To: DRMS
• Annual Report Year: 2016
• Email Name: AME
• 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: Mark Dorenkemp
Permittee Company: Prowers County
Address: 109 E. Sherman St.
Lamar, CO 81052
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Tony Garcia
Company: Prowers County
Address: 109 E. Sherman St.
Lamar, CO 81052
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Tony Garcia
Company: Prowers County
Address: 109 E. Sherman St.
Lamar,CO 81052
Phone Number: [phone]
Fax Number:
Email Address:
1,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted iyn' accordance with the pivision approved mining and reclamation plans.
L
Signature of Permittee Co orate- O— icer,Owner,or Documented Designee Date
M-AF-04