2017-02-16_REPORT - M1987009

• Permit No: M1987009
• IBM Index Class Name: REPORT
• Doc Date: 2/16/2017
• Doc Name: Annual Fee/Report/Map
• From: Prowers County
• To: DRMS
• Annual Report Year: 2017
• Email Name: AME
• 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: Mark Dorenkamp
Permittee Company: Prowers County
Address: 109 E. Sherman St.
Lamar, CO 81052
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Mark Dorenkamp
Company: Prowers County
Address: 301 S.Main, Ste.215
Lamar, CO 81052
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Mark Dorenkamp
Company: Prowers County
Address: 301 S.Main, Ste. 215
Lamar,CO 81052
Phone Number: [phone]
Fax Number:
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 Divis' n appr ved ining and reclamation plans.
Signature of Permittee Cor .or Officer,Owner,or Documented Designee Date
M-A-04