2017-03-14_REPORT - M1995009

• Permit No: M1995009
• IBM Index Class Name: REPORT
• Doc Date: 3/14/2017
• Doc Name: Annual Fee/Report/Map
• From: Dorman Brothers LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Michael B.Dorman
Permittee Company: Dorman Brothers LLC
Address: 70 Webster Ave.
Burlington,CO 80807
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Michael B.Dorman
Company: Dorman Brothers LLC
Address: 70 Webster Ave.
Burlington, CO 80807
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Michael B.Dorman
Company: Dorman Brothers LLC
Address: 70 Webster Ave.
Burlington,CO 80807
Phone Number: [phone]
Fax Number: [phone]
Email Address:
I,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are
being conducte ' acco ce with the Division approved mining and reclamation plans.
—1
Signature of Permitift,Coro OMcer,Owner,or'bkcumented Desi nee Date
M-AF-01