2017-01-17_REPORT - M1999077 ‎(3)‎

• Permit No: M1999077
• IBM Index Class Name: Report
• Doc Date: 1/17/2017
• Doc Name: Annual Fee/Report/Map
• From: Montezuma County
• To: DRMS
• Annual Report Year: 2015
• Email Name: LJW
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee contact information. If this information is not current, please type or print
current contact information:
Permittee Contact:
I jWA_Euesett
Permittee Company:
Montezuma Couuiy
Address:
1680 North Dolores Road
Cortez, CO 81321
r
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
5'
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
M•AF-6!
Owner, or Documented Designee
k-15
Date