2017-02-08_REPORT - M2008017

• Permit No: M2008017
• IBM Index Class Name: REPORT
• Doc Date: 2/8/2017
• From: Broken Arrow Investments LLC
• To: DRMS
• Annual Report Year: 2016
• Email Name: PSH
• 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: Doug Derr
Permittee Company: Broken Arrow Investments LLC
Address: 801 8th St., Ste. 130
Greeley, CO 80631-3903
Phone Number: [phone] _
Fax Number:
Email Address:
Permitting Contact: J.C.York
Company: J&T Consulting, Inc.
Address: 1400 W. 122nd Ave., Ste. 120
Westminster, CO 80234
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Darwin Derr
Company: Broken Arrow Investments, LLC
Address: 699 N. First Avenue
Greeley, CO 80631
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.
x- s
signature of Per i ee Co a e Officer.Owner,or Documented Designee Date
M-AF-01