2017-04-25_REPORT - M1984039

• Permit No: M1984039
• IBM Index Class Name: REPORT
• Doc Date: 4/25/2017
• Doc Name: Annual Fee/Report/Map
• From: Wilbur Benham
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• Media Type: D
• Archive: No

Page 5 of 5
Division wcords indicate the following permittee/landowner contact information (blank fields indicate that we do not have
intfirmation on record). If this information is blank or not current, please type or print current contact information:
Permittee Contact:
Wilbur F. Benham
Permittee Company:
Wilbur F Benham
Address:
16417 KQNK Rd.
Box 66
Norton, KS 67654
Phone Number:
[phone]
Fax Number:
�t
Email Address:
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Permitting Contact:
�y
Company:
Wilbur F Benham
Address:
16417 KQNK Rd
Box 66
Norton, KS 67654
Phone Number:
[phone]
Fax Number:
N d N C
Email Address:
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Inspection Contact:
Company:
Wilbur F Benham
Address:
16417 KQNK Rd
Box 66
Norton, KS 67654
Phone Number:
[phone]
Fax Number:
/w
Email Address:
O
1, 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.
of Permittee. Corporate Offider, Owner, or Documented Designee
til AF.-1-
0310-1%
Date