2017-04-14_REPORT - M2012027

• Permit No: M2012027
• IBM Index Class Name: REPORT
• Doc Date: 4/14/2017
• Doc Name: Annual Fee/Report/Map
• From: B & L Cogan
• To: DRMS
• Annual Report Year: 2017
• Email Name: DMC
• 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: Laurie Jacobson
Permittee Company: B &L Cogan,L.L.C.
Address: 24800 US. Hwy 285 S.
Buena Vista,CO 81211
Phone Number: [phone]
Fax Number:
Email Address: �[e-mail]
'q-y as, CoC)7
Permitting Contact: Laurie Cogan Jacobson
Company: McQuaid LLC
Address: 24800 U.S.Hwy. 285 S.
Buena Vista,CO 81211
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
L�, C "cl "low . CG`'�-n
Inspection Contact: Laurie Cogan.Gegaa-3acobson i n e ��'
Company: McQuaid LLC �q,U �b
Address: 24800 U.S. Hwy. 285 S.
Buena Vista,CO 81211
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 con ucted in accordan th the Div ion approved mining and reclamation plans.
Signature of Permitte Cor orate Officer,Owner,or Documented Designee Date
M-AF-01