2017-05-16_REPORT - M1989030

• Permit No: M1989030
• IBM Index Class Name: REPORT
• Doc Date: 5/16/2017
• Doc Name: Annual Fee/Report/Map
• From: San Miguel County
• To: DRMS
• Annual Report Year: 2016
• Email Name: LJW
• 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:
4MW Zwoe0-r,
Permittee Company: San Miguel County
Address: P.O. Box 426
Norwood,CO 81423
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Mike+ferner
ZVA, 246WErl?
Company: San Miguel County
Address: P.O. Box 426
Norwood, CO 81423
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: "Ake Rome.
�CY4AI V69NET71
Company: San Miguel County
Address: P.O. Box 426
Norwood, CO 81423
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.
Signatu PerwAfee. Cor orate Officer,Owner,or Documented Desiene 6ate
M-AF-04