2017-02-17_REPORT - M2008072

• Permit No: M2008072
• IBM Index Class Name: REPORT
• Doc Date: 2/17/2017
• Doc Name: Annual Fee/Report/Map
• From: Tim Carper
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Tim Carper
Permittee Company: Tim Carper
Address: 42538 Co.Rd. 09
Haxtun,CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact: Tim Carper
Company: Tim Carper
Address: 42538 Co. Rd. 09
Haxtun, CO 80731
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
1,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.
2-17 -17
Si nature of Pe 1W.Corporate Officer,Owner,or Documented Designee Date
M-AF-01