2017-04-12_REPORT - M2006009

• Permit No: M2006009
• IBM Index Class Name: REPORT
• Doc Date: 4/12/2017
• Doc Name: Annual Fee/Report/Map
• From: Mesa Sandstone, LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• 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: William K. Goode
Permittee Company: Mesa Sandstone,LLC
Address: P.O. Box 220
Cortez,CO 81321
Phone Number: [phone]
Fax Number: [phone]
Email Address: William—[e-mail]
Permitting Contact:
Company:
Address:
I ,`5 r" 81321
Phone Number: -
Fax Number: - 94
Email Address:
Inspection Contact: b William K.Goode
Company: Mesa Sandstone,LLC
Address: P.O. Box 220
Cortez,CO 81321
Phone Number: [phone]
Fax Number: i [phone]
Email Address: William—[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 cordance with the Division approved mining and reclamation plans.
Signature of Permit lee,Cor rate Officer,Owner,or Documented Designee Date
M-AF-01