2017-02-08_REPORT - M1985170

• Permit No: M1985170
• IBM Index Class Name: REPORT
• Doc Date: 2/8/2017
• Doc Name Note: Annual Report and Map
• Doc Name: Annual Report and Map
• From: CDOT
• To: DRMS
• Annual Report Year: 2017
• Email Name: ACY
• 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: Kane Schneider
Permittee Company: Colorado Department of
Transportation
Address: 606 S. 9th St.
Grand Junction, CO 81501
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Kane Schneider
Company: Colorado Department of
Trans ortation
Address: 606 S. 9th St.
Grand Junction, CO 81501
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Inspection Contact: Kane Schneider
Company: Colorado Department of
Transportation
Address: 606 S. 9th St.
Grand Junction, CO 81501
Phone Number: [phone]
Fax Number: [phone]
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 accordance with the Division approved mining and reclamation plans.
/./,1�24 K, -..� l- 2 -
Signat r of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-04