2017-05-08_REPORT - M1978085

• Permit No: M1978085
• IBM Index Class Name: REPORT
• Doc Date: 5/8/2017
• Doc Name: Annual Fee/Report/Map
• From: Moffat County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ACY
• 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: [eek
Dan Miller
Permittee Company: Moffat County
Address: P.O.Box 667
Craig, CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address:
[e-mail] 1/
Permitting Contact: Teff 9. enaper
Dan Miller t/
Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone] v
Email Address:
[e-mail]
Inspection Contact: er
Dan Miller
Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
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.
04/18/2017
Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date
M"-04