2017-03-10_REPORT - M2014005

• Permit No: M2014005
• IBM Index Class Name: REPORT
• Doc Date: 3/10/2017
• Doc Name: Annual Fee/Report/Map
• From: O'Rourke Excavating, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: THM
• 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: Thomas O'Rourke
Permittee Company: O'Rourke Excavating, Inc.
Address: 581 CR 18 1,e-1 o —DQ rl i e-( C R eq -e
South Fork,CO 81154
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Thomas O'Rourke
Company: O'Rourke Excavating, Inc.
Address: 2489 CR 15 yC3 Dcz n i e Zu V
South Fork, CO 81154
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Thomas O'Rourke
Company: O'Rourke Excavating, Inc.
Address: 2489 CR 15 L fU � ,,Z i of ( cz r-, e
South Fork, CO 81154
Gl D
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 conduct9on accordance with the Division approved mining and reclamation plans.
Signatu ermittee,Corporate Chicer,d6ner,or Documented Desianee Date
M-AF-01