2017-02-09_REPORT - M1977227

• Permit No: M1977227
• IBM Index Class Name: Report
• Doc Date: 2/9/2017
• Doc Name: Annual Fee/Report/Map
• From: Super Ex., LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• Media Type: D
• Archive: No

Division records indic.ttc the hollowing perntinec/landowner contact information(blank fields indicate tPage have
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inibrati(ml on record'. 11,11,is inliirnntttion is blank or not curren hat we d
t,please type or print current contact infortn<ttion:
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Perntiftee company: y _ -
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Address:
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Phone Number:
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Permitting('ontacl:
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ontpany:
Address: _
Phone Number:
FaxNumher:
!,mail Address: _
(inspection Contact: _
Company
Address:
Phone Number:
Fax Number:
Finail Address:
I,the undersigned, here>y s-atc that the information provided in this report is true and accurate,and that site operations are
being conducted in accc R anee with the Division approved mining and reclamation plans.
gnat tire of Permtttee,I-tt;rporate Officer,Owner,or Documented Desiener
M NF-of Date