2017-03-10_REPORT - M1980052

• Permit No: M1980052
• IBM Index Class Name: REPORT
• Doc Date: 3/10/2017
• Doc Name: Annual Fee/Report/Map
• From: Keith Holsinger
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• 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: Keith Holsinger
Permittee Company: Keith Holsinger
Address: P.O. Box 37
Walden,CO 80480
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Keith Holsinger
Company: Keith Holsinger
Address: P.O. Box 37
Walden, CO 80480
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Keith Holsinger
Company: Keith Holsinger
Address: P.O. Box 37
Walden,CO 80480
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 Division approved mining and reclamation plans.
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Signature Permittee or orate Offc r,Owner,or Documented Designee Date
M-AF-01