2017-05-30_M2012008_Annual Fee Notice ARCHIVE

• Permit No: M2012008A
• IBM Index Class Name: Report
• Doc Date: 5/30/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: City of Las Animas
• 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:

Ken Wagner
Permittee Company:

City of Las Animas
Address:

532 Carson Avenue
P.O. Box 468
Las Animas, CO 81054

Phone Number:

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

Ken Wagner
Company:

City of Las Animas
Address:

532 Carson Avenue
P.O. Box 468
Lass Animas, CO 81054

Phone Number:

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

Ronda Bucholz
Company:

Bent County Courthouse
Address:

725 Bent Avenue
P.O. Box 350
Las Animas, CO 81054

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