2017-04-12_REPORT - M1980244 ‎(6)‎

• Permit No: M1980244
• IBM Index Class Name: Report
• Doc Date: 4/12/2017
• Doc Name: Annual Fee/Report/Map
• From: CC&V
• To: DRMS
• Annual Report Year: 2017
• Email Name: TC1
• 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:
Jack Henris
Permittee Company:
Cripple Creek & Victor Gold
Mining Com an
Address:
100 N. 3rd Street
P. O. Box 191
Victor, CO 80860
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
Permitting Contact:
Jack Henris
Company:
Cripple Creek & Victor Gold
Address:
100 North Third Street
P.O. Box 191
Victor, CO 80860-0191
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
Inspection Contact:
Cheyne Mann
Company:
Cripple Creek & Victor Gold
Address:
100 North Third Street
P. O. Box 191
Victor, CO 80860-0191
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.
qzl-
Signature of
M -AF -02
Owner, or Documented Designee
M./
ate