2017-03-14_REPORT - M2011014

• Permit No: M2011014
• IBM Index Class Name: REPORT
• Doc Date: 3/14/2017
• Doc Name: Annual Fee/Report/Map
• From: Dale and Ellen Schmidt
• 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: Dale Schmidt
Permittee Company: Dale and Ellen Schmidt
Address: 472 Meadows Dr.
Pagosa Springs,CO 81147
Phone Number: [phone]
Fax Number: 070 73 ` i
Email Address: O s L ) L,� 1 a
T/ I[ r ,
Permitting Contact: Nathan A.Barton
Company: Wasteline, Inc.
Address: P.O. Box 88
Cortez, CO 81321-0088
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact:
Company:
Address:
Phone Number:
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 jthe Division approved mining and reclamation plans.
Signature of Permittee,eorporate Officer,Owner,or Documented Designee Date
M-AF-01
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