2017-06-14_REPORT - M2000066

• Permit No: M2000066
• IBM Index Class Name: REPORT
• Doc Date: 6/14/2017
• Doc Name: Annual Fee/Report/Map
• From: Lincoln County
• To: DRMS
• Annual Report Year: 2017
• Email Name: TC1
• 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: Jeffrey D.Coonts Try y �6rm,e,5
Permittee Company: Lincoln County
Address: P.O. Box 39
Hugo, CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr—[e-mail]
Permitting Contact: John DeWitt T rp—Y
Company: Lincoln County
Address: P.O. Box 39
Hugo,CO 80821
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: John DeWitt re Tgnie,,i;
Company: Lincoln County
Address: P.O. Box 39
Hugo, CO 80821
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.
Signat of tee Cor orate Officer,Owner,or Documented Desiinee Date
M-AF-04