2017-05-19_M2004021_Annual Fee Notice ARCHIVE

• Permit No: M2004021A
• IBM Index Class Name: Report
• Doc Date: 5/19/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Washington County
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

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:

Jeremy Wells
Permittee Company:

Washington County
Address:

150 Ash Avenue
Akron, CO 80720

Phone Number:

[phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:

Randy Schafer
Company:

Randy Schafer
Address:

40586 CR 21
Haxtun, CO 80731

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Inspection Contact:

Jason Lockard
Company:

Washington County Road and Bridge
Address:

150 Ash Avenue
Akron, CO 80720

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.

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date

M-AF-04