2017-03-17_REPORT - M1984013

• Permit No: M1984013
• IBM Index Class Name: Report
• Doc Date: 3/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: George Otten
• Annual Report Year: 2017
• Permit Index Doc Type: Annual Fee/Report
• 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:

George E. Otten
Permittee Company:

George E. Otten
Address:

11438 CR 19
Fort Lupton, CO 80621

Phone Number:

[phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:

George E. Otten
Company:

George E. Otten
Address:

7546 S. Elati Street
Littleton, CO 80120

Phone Number:

[phone]
Fax Number:
Email Address:
Inspection Contact:

George E. Otten
Company:

George E. Otten
Address:

7546 S. Elati Street
Littleton, CO 80120

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.

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date
M-AF-02