2017-03-28_REPORT - M1977522

• Permit No: M1977522
• IBM Index Class Name: REPORT
• Doc Date: 3/28/2017
• Doc Name: Annual Fee/Report/Map
• From: L.G. Everist, Incorporated
• To: DRMS
• Annual Report Year: 2017
• Email Name: ECS
• 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: Lynn M. Sjhults �\ `
Permittee Company: L. G. Everist,Incorporated
Address: 7321 E. 88th Avenue, Suite 200
Henderson, CO 80640
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Dennis Fields Lynn
Company: L. G. Everist,Incorporated
Address: 7321 E. 88th Avenue, Suite 200
Henderson, CO 80640
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Dennis Fields
Company: L. G. Everist,Incorporated
Address: 7321 E. 88th Avenue, Suite 200
Henderson, CO 80640
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 accoydance wit the vision approved mining and reclamation plans.
Zel
-"Z/
Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01