2017-03-17_REPORT - M2012027

• Permit No: M2012027
• IBM Index Class Name: Report
• Doc Date: 3/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: B & L Cogan LLC
• 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:

Laurie Jacobson
Permittee Company:

B & L Cogan, L.L.C.
Address:

24800 US. Hwy 285 S.
Buena Vista, CO 81211

Phone Number:

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

Laurie Cogan Jacobson
Company:

McQuaid LLC
Address:

24800 U.S. Hwy. 285 S.
Buena Vista, CO 81211

Phone Number:

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

Laurie Cogan Cogan Jacobson
Company:

McQuaid LLC
Address:

24800 U.S. Hwy. 285 S.
Buena Vista, CO 81211

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-01