2017-01-09_REPORT - M1999069

• Permit No: M1999069
• IBM Index Class Name: REPORT
• Doc Date: 1/9/2017
• Doc Name: Annual Fee/Report/Map
• From: Jake Kauffman & Son, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: ECS
• Media Type: D
• Archive: No

' I 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: Mary Kauffman
Permittee Company: Jake Kauffman& Son, Inc.
Address: 808 S. County Road 9E
Loveland, CO 80537
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact: Frank Kauffinan
Company: Jake Kauffman& Son, Inc
Address: 808 SCR 9E
Loveland, CO 80537
Phone Number: [phone]
Fax Number: [phone]
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 in accordance with the Division approved mining and reclamation plans.
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Signature Permi e, Corporate Of icer,Owner,or Documented Designee Date
M-AF-01