2017-03-06_REPORT - M1995057

• Permit No: M1995057
• IBM Index Class Name: REPORT
• Doc Date: 3/6/2017
• Doc Name: Annual Fee/Report/Map
• From: Deb Rudibaugh
• To: DRMS
• Annual Report Year: 2017
• Email Name: DMC
• 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: Deb Rudibaugh
Permittee Company: Deb Rudibaugh
Address: 5291 CR 76
Parlin, CO 81239
Phone Number: [phone]
Fax Number:
Email Address: Ranch-711 @yahoo.com
V,
Permitting Contact: Deb Rudibaugh
Company: Deb Rudibaugh
Address: 5291 CR 76
Parlin, CO 81239
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Deb Rudibaugh
Company: Deb Rudibaugh
Address: 5291 CR 76
Parlin, CO 81239
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 con ted in accordance with the Division approved mining and reclamation plans.
�) 6�� - 1 -
Signature of Perm tee.Corporate icer, ner,or Documented Designee Date
M-AF-01