2016-12-08_REPORT - M2010054

• Permit No: M2010054
• IBM Index Class Name: REPORT
• Doc Date: 12/8/2016
• Doc Name: Annual Fee/Report/Map
• From: Timothy D. & Betty J. Williams
• To: DRMS
• Annual Report Year: 2016
• Email Name: MAC
• 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: Timothy D.Williams
Permittee Company: Timothy D. Williams&Betty J.
Williams
Address: P.O. Box 455
Walsenburg, CO 81089
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Timothy D.Williams
Company: Timothy D. Williams&Betty J.
Williams
Address: 5588 CR 210
Walsenburg, CO 81089
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Timothy D. Williams
Company: Timothy D. Williams &Betty J.
Williams
Address: 5588 CR 210
Walsenburg, CO 81089
Phone Number: [phone]
Fax Number:
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 PerMidee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01