2017-06-26_REPORT - M1997011

• Permit No: M1997011
• IBM Index Class Name: REPORT
• Doc Date: 6/26/2017
• Doc Name: Annual Fee/Report/Map
• From: Baculite Mesa, LLC
• To: DRMS
• Annual Report Year: 2017
• 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: Fred J.Orr
Permittee Company: Baculite Mesa, LLC
Address: 5040 Acoma Street
Denver,CO 80216-2010
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
1,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.
Q.� o
Signature of Permittie,torporateOfficer,Owlier,or Documented Designee Date
Mdi-01