2017-04-28_REPORT - M2000040

• Permit No: M2000040
• IBM Index Class Name: Report
• Doc Date: 4/28/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Medicine Bow - Routt National Forest USDA Forest Service
• Annual Report Year: 2017
• 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:

Nate Davis
Permittee Company:

Medicine Bow - Routt National
Forest USDA Forest Service

Address:

2568 Jackson St.
Larime, WY 82070-6535

Phone Number:

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

Dennis Gale
Company:

U.S.D.A. Forest Service, Parks
Ranger District

Address:

210 S. 6th St.
P.O. Box 1210
Kremmling, CO 80459

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Inspection Contact:

Dennis Gale
Company:

U.S.D.A. Forest Service, Parks
Ranger District

Address:

210 S. 6th St.
P.O. Box 1210
Kremmling, CO 80459

Phone Number:

[phone]
Fax Number: [phone]
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-04