2017-06-08_REPORT - M2010084

• Permit No: M2010084
• IBM Index Class Name: REPORT
• Doc Date: 6/8/2017
• Doc Name: Annual Fee/Report/Map
• From: Lost Cause, LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: THM
• 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: Tim Mantle
Permittee Company: Lost Cause, LLC
Address: 27002 CR 5
Rifle, CO 81650
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Roberta Tabor
Company:
Address: P.O. Box 266
Loma,CO 81524
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Michael Frick
Company:
Address: P.O. Box 266
Loma, CO 81524
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 Da
M-AF-01