2017-02-06_REPORT - M2004001

• Permit No: M2004001
• IBM Index Class Name: REPORT
• Doc Date: 2/6/2017
• Doc Name: Annual Fee/Report/Map
• From: Lincoln County
• 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: - wiift-
Je ' C,C) n ` r/
Permittee Company: Lincoln County
Address: P.O. Box 39
Hugo,CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: ...UlaDe t
:a;e ce 0
Company: Lincoln County
Address: P.O. Box 39
Hugo, CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Sohn De b`itr
Co
Company: Lincoln County
Address: P.O. Box 39
Hugo, CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
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.
(:�� /P - 1 _19 - 17
r fk4oee.Cor orate Officer,Owner,or Documented Designee Date
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