2017-01-20_REPORT - M1980249

• Permit No: M1980249
• IBM Index Class Name: REPORT
• Doc Date: 1/20/2017
• Doc Name: Annual Fee/Report/Map
• From: Charles W. Houchin
• To: DRMS
• Annual Report Year: 2017
• Email Name: TC1
• 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: Curt Houchin
Permittee Company: Charles W Houchin
Address: P.O.Box 85
Green Mountain Falls,CO
80819
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact:
Company: Charles W Houchin
Address: P.O.Box 162
Green Mountain Falls,CO
80819
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact:
Company: Charles W Houchin
Address: P.O.Box 162
Green Mountain Falls,CO
80819
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
I,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are
being conducted in accor*an a ith the Divisio approved mining and reclamation plans.
Signature of Permittee.Corporate Officer,Owner,or Documented Designee Date
M-AF-01