2017-03-06_REPORT - M1999073 ‎(2)‎

• Permit No: M1999073
• IBM Index Class Name: Report
• Doc Date: 3/6/2017
• Doc Name: Annual Fee/Report/Map
• From: Evan L. Melby, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• 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:
Evan Melby
Permittee Company:
Evan L. Melby, Inc.
Address:
P.O. Box 4159
Ventura, CA 93007
Phone Number:
[phone]
Fax Number:
(805 1
)r5 ,
Email Address:
Emel .Com
Permitting Contact:
Evan L. Melby
Company:
Evan L. Melby, Inc.
Address:
P.O. Box 4159
Ventura, CA 93007
Phone Number:
[phone]
Fax Number:
(80
f
Email Address:
Inspection Contact:
Evan L. Melby
Company:
Evan L. Melby, Inc.
Address:
P.O. Box 4159
Ventura, CA 93007
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:�'W'yw
�l
I, the undersigned, hereby state that the information ploy ded in this report is true and accurate, and that site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
Vt 'S 2L -7
Si ure of Permittee Corporate 0itL
e Owner, Toocullmlented Desi nee Date
M -AF -01