2017-03-17_REPORT - M2016018

• Permit No: M2016018
• IBM Index Class Name: Report
• Doc Date: 3/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: Town of La Veta
• 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:

Douglas R. Brgoch
Permittee Company:

Town of La Veta
Address:

P.O. Box 174
111 W. Moore
La Veta, CO 81055

Phone Number:

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

Laurie L. Erwin
Company:

Town of La Veta
Address:

111 W. Moore Ave.
P.O. Box 174
La Veta, Co 81055

Phone Number:

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

Laurie L. Erwin
Company:

Town of La Veta
Address:

111 W. Moore Ave.
P.O. Box 174
La Veta, CO 81055

Phone Number:

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

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-04