2017-02-06_REPORT - M2010082 ‎(2)‎

• Permit No: M2010082
• 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: T- 9hn4)eW4ft---
-3-lefic L00�X-�
Permittee Company: Lincoln County
Address: P.O.Box 39
Hugo,CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: -Johni)eWftt
Company: Lincoln County
Address: P.O. Box 39
Hugo,CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact:
-j7e-4 ' Ce v Y+ t3
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.
- /7
Signatur�r , orate Officer,Owner,or Documented Desi¢nee Date
M-AF-04