2017-03-17_REPORT - M1978327

• Permit No: M1978327
• IBM Index Class Name: Report
• Doc Date: 3/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: Jake Kaufman & Son
• 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:

Mary Kauffman
Permittee Company:

Jake Kauffman & Son, Inc.
Address:

808 SCR 9E
Loveland, CO 80537

Phone Number:

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

Mary Kauffman
Company:

Jake Kauffman & Son, Inc
Address:

808 SCR 9E
Loveland, CO 80537

Phone Number:

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

Mary Kauffman
Company:

Jake Kauffman & Son, Inc
Address:

808 SCR 9E
Loveland, CO 80537

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