2017-03-17_REPORT - M1977071

• Permit No: M1977071
• IBM Index Class Name: Report
• Doc Date: 3/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: Lake County
• 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:

Brad Palmer
Permittee Company:

Lake County
Address:

P.O. Box 952
Leadville, CO 80461

Phone Number:

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

Kent Hager
Company:

Lake County
Address:

County Administrator
P.O. Box 964
Leadville, CO 80461

Phone Number:

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

Steve Kleeberger
Company:

Lake County
Address:

Road & Bridge Supervisor
P.O. Box 964
Leadville, CO 80461

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-04