2017-06-13_REPORT - M2011049

• Permit No: M2011049
• IBM Index Class Name: REPORT
• Doc Date: 6/13/2017
• Doc Name: Annual Fee/Report/Map
• From: City of Greeley
• To: DRMS
• Annual Report Year: 2017
• Email Name: AME
• 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 ty pe or print current contact information:
Permittee Contact: Anastasia Frantsova
Permittee Company: City of Greeley
Address: 1100 I Oth Street, Suite 300
Greeley,CO 80631
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Bill Schenderlein
Company: Blue Earth
Address: P.O. Box 2427
Fort Collins,CO 80522
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Randy Gustafson
Company: City of Greeley
Address: 1100 1 Oth Street, Suite 300
Greeley, CO 80631
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-4F-U1