2017-01-26_REPORT - M2014061

• Permit No: M2014061
• IBM Index Class Name: Report
• Doc Date: 1/26/2017
• Doc Name: Annual Fee/Report/Map
• From: Schlosser Incorporated
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Levi Schlosser
Permittee Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington, CO 80807
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
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Permitting Contact: Levi Schlosser
Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington, CO 00000
Phone Number: [phone]
Fax Number: `7 f f- 396
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Email Address: [e-mail]
Inspection Contact: Levi Schlosser c�U1
Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington, CO 04OW-
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Phone Number: [phone]
Fax Number: 7
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Email Address: [e-mail] SL��oSSG� �4�i�of' 'd���•CO'"'
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.
Sign re of Permittee, orporate Officer,Owner,or Documented Designee D to
M-AF-01