2017-04-28_REPORT - M2014008

• Permit No: M2014008
• IBM Index Class Name: Report
• Doc Date: 4/28/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Washington County
• 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:

Steve Williams
Permittee Company:

Washington County
Address:

11920 Co. Rd. CC
P.O. Box 32
Anton, CO 80801

Phone Number:

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

Randy Scjafer
Company:

Address:

40586 County Rd. 21
Haxtun, CO 80731

Phone Number:

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

Steve Williams
Company:

Washington County
Address:

11920 Co. Rd. CC
P.O. Box 32
Anton, CO 80801

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