2016-12-23_REPORT - M2008022

• Permit No: M2008022
• IBM Index Class Name: REPORT
• Doc Date: 12/23/2016
• Doc Name: Annual Fee/Report/Map
• From: 4B Land & Livestock LLC
• To: DRMS
• Annual Report Year: 2016
• Email Name: ACY
• 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: Scott R.Brennise
Permittee Company: 4B Land&Livestock LLC
Address: 5801 Highway 394
Craig,CO 81625
Phone Number: [phone]
Fax Number:
Email Address:
Permitting Contact: Sheila Brennise
Company: 4B Land&Livestock LLC
Address: 5801 HWY 394
Craig,CO 81625
Phone Number: [phone]
Fax Number:
Email Address: Dnr—[e-mail]
Inspection Contact: Jon Mueller
Company: 4B Land&Livestock LLC
Address: 556 Struthers Ave.
Grand Junction, CO 81501-
3826
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 ' ordance with the Division approved mining and reclamation plans.
!a /6 o
Signature of Perm'. ee Coruorate O icer,Owner,or Documented Designee Date
M-AP-01