2017-01-17_REPORT - M2014045

• Permit No: M2014045
• IBM Index Class Name: Report
• Doc Date: 1/17/2017
• Doc Name: Annual Fee/Report Notice
• From: DRMS
• To: Mineral Mountain
• 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:

Lance Barker
Permittee Company:

Mineral Mountain Gold, LLC
Address:

P.O. Box 247
Cripple Creek, CO 80813

Phone Number:

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

Lance Barker
Company:

Mineral Mountain Gold, LLC
Address:

P.O. Box 247
Cripple Creek, CO 80813

Phone Number:

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

Lance Barker
Company:

Mineral Mountain Gold, LLC
Address:

P.O. Box 247
Cripple Creek, CO 80813

Phone Number:

[phone]
Fax Number:
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-02