2017-05-09_REPORT - M2016018

• Permit No: M2016018
• IBM Index Class Name: REPORT
• Doc Date: 5/9/2017
• Doc Name: Annual Fee/Report/Map
• From: Town of La Veta
• To: DRMS
• Annual Report Year: 2016
• Email Name: ECS
• 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: Douglas R.Brgoch
Permittee Company: Town of La Veta
Address: P.O. Box 174
111 W.Moore
La Veta,CO 81055
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]901
Permitting Contact: Laurie L.Erwin
Company: Town of La Veta
Address: 111 W.Moore Ave.
P.O. Box 174
La Veta,Co 81055
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr—[e-mail] `
v��aG'C'Owno QF (C�\le_}a—or, roe/
Inspection Contact: Laurie L.Erwin
Company: Town of La Veta
Address: 111 W.Moore Ave.
P.O. Box 174
La Veta,CO 81055
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr [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.
Si ture of Per e ,Corporate Offficer,Owner,or Documented Desiunee Date
M-AF-04