2017-05-08_REPORT - M2005006

• Permit No: M2005006
• 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:
Dan Miller
Permittee Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: `--`-
Dan Miller
Company:
Moffat County Road & Bridge `
Address: Fmlmey PO Box 667 �
' Craig, CO 81626
Phone Number:
[phone] �
Fax Number: [phone]
Email Address:
Inspection Contact:
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.
5 2 �7
Signature of Permittee. Coraor to Officer.Owner,or Documented Designee Date
M AF-W