2017-05-25_REPORT - M1982098

• Permit No: M1982098
• IBM Index Class Name: REPORT
• Doc Date: 5/25/2017
• Doc Name: Annual Fee/Report/Map
• From: Kit Carson County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ERR
• 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: Paula Weeks
Permittee Company: Kit Carson County
Address: P.O. Box 160
Burlington,CO 80807
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: LxRey-Herndon
Company: Kit Carson County
Address: 215 16th St
Burlington, CO 80807
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: LQgoy Hernden
Company: Kit Carson County
Address: 215 16th St
Burlington,CO 80807
Phone Number: [phone]
Fax Number:
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.
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Signature of Permittee,Corporatee6fricer,Owner,or Documented Designee Date
M-AF-04