2017-04-17_M2012014_Annual Fee Notice ARCHIVE

• Permit No: M2012014A
• IBM Index Class Name: Report
• Doc Date: 4/17/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Dietzler Construction Corporation
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

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:

John Dietzler
Permittee Company:

Dietzler Construction Corporation
Address:

5027 CR 37
Yoder, WY 82244

Phone Number:

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

Mickey Leyba Farnsworth
Company:

Patrick Engineering
Address:

1400 W. 122nd Ave., Suite 102
Westminster, CO 80234

Phone Number:

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

Joel Slate
Company:

Dietzler Construction Corporation
Address:

1306 Main Street
Torrington, WY 82240

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