2017-03-13_REPORT - M1977534

• Permit No: M1977534
• IBM Index Class Name: REPORT
• Doc Date: 3/13/2017
• Doc Name: Annual Fee/Report/Map
• From: City of Golden
• To: DRMS
• Annual Report Year: 2017
• Email Name: MAC
• Media Type: D
• Archive: No

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Division records indicate the to]lo��ing permittee/lando�%ner contact information(blank fields indicate that ��e do not have
information on record). If this information is blank or not current, please type or print current contact information:
Permittee Contact: Dan Hartman
Permittee Company: City of Golden
Address: Director of Public Works
911 Tenth St.
Golden. CO 80401
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dhartman(a cityofgolden.net
Permitting Contact: Dan Hartman
Company: City of Golden
Address: Director of Public Works
911 Tenth St.
Golden. CO 80401
Phone Number: [phone]
Fax Number: [phone]
Email Address: `
Ck lltt �'�m(.i ,t.- a,e n 116
Inspection Contact: Dan Hartman
Company: City of Golden
Address: Director of Public Works
911 Tenth St.
Golden. CO 80401
Phone Number: [phone]
Fax Number: [phone]
Email Address: h t �� l �� l j G �,l A e 41
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.
Signature of Permittee, Corporate Officer, Owner,or Documented Designee Date