2017-01-31_REPORT - M1985140

• Permit No: M1985140
• IBM Index Class Name: REPORT
• Doc Date: 1/31/2017
• Doc Name: Annual Fee/Report/Map
• From: David Goss
• 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: Dean Goss
Permittee Company: David Goss
Address: 24040 Falcon Hwy
Calhan, CO 80808-9156
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Dean Goss
Company: David Goss
Address: 24040 Falcon Hwy
Calhan, CO 80808-9156
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Dean Goss
Company: David Goss
Address: 24040 Falcon Hwy
Calhan, CO 80808-9156
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.
46:4-f6 ALL 1122,111-
Signature of Permittee. Corporate Officer,Owner,or Documented Designee Date
M-AF-01