2016-12-21_REPORT - M2009062

• Permit No: M2009062
• IBM Index Class Name: REPORT
• Doc Date: 12/21/2016
• Doc Name: Annual Fee/Report/Map
• From: Weld County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ECS
• 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: Clay Kimmi
Permittee Company: Weld County
Address: 1111 H St.
P.O. Box 758
Greeley, CO 80632
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Dftvia B-. D
C I�•y K,rr.m (
Company: Weld County Public Works
Address: 1111 H Street
P O Box 758
Greeley, CO 80632
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: G.eg Nelson K.-m(
Company: Weld County Public Works
Address: 1111 H Street
P O Box 758
Greeley, CO 80632
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.
1 .
Signat r of Permittee, Corporate Officer,Owner,or Documented Designee Date
M-AF-04