2017-05-16_REPORT - M1977071

• Permit No: M1977071
• IBM Index Class Name: Report
• Doc Date: 5/16/2017
• Doc Name Note: Signature page
• Doc Name: Annual Fee/Report/Map
• From: Lake County
• To: DRMS
• Email Name: DMC
• 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:
Brad Palmer
Permittee Company:
Lake County
Address:
P.O. Box 952
Leadville, CO 80461
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
Permitting Contact:
Kent Hager
.
Company:
Lake County
LAM
Address:
County Administrator
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P.O. Box 964
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Leadville, CO 80461
Phone Number:
[phone]
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Fax Number:
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Email Address:
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Inspection Contact:
Steve Kleeberger
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*v '--'v "/V/Company:
Lake County
Address:
Road & Bridge Supervisor
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P.O. Box 964
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Leadville, CO 80461
Phone Number:
[phone]
Fax Number:
717 /
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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 i:,ordance with the Divis' n approved mining and reclamation plans.
Owner, or Documented Designee
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Date