2017-03-03_REPORT - M2014045

• Permit No: M2014045
• IBM Index Class Name: REPORT
• Doc Date: 3/3/2017
• Doc Name: Annual Fee/Report/Map
• From: Mineral Mountain Gold, LLC
• 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: Lance Barker
Permittee Company: Mineral Mountain Gold,LLC
Address: P.O. Box 247
Cripple Creek,CO 80813
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Lance Barker
Company: Mineral Mountain Gold,LLC
Address: P.O. Box 247
Cripple Creek, CO 80813
Phone Number: [phone]
Fax Number: _ 069 _6-q/'
Email Address: [e-mail]
Inspection Contact: Lance Barker
Company: Mineral Mountain Gold,LLC
Address: P.O.Box 247
Cripple Creek,CO 80813
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
I,the un rsigned,hereby state that the information provided in this report is true and accurate,and that site operations are
being n ucted in acco, ce wit a Division approved mining and reclamation plans.
Q0)
Sign ture o Permi ee,Corporate Officer,Owner,or Documented Designee ate
M AF-02