2017-06-27_REPORT - M2012016

• Permit No: M2012016
• IBM Index Class Name: REPORT
• Doc Date: 6/27/2017
• Doc Name: Annual Fee/Report/Map
• From: Puckett Land Company
• To: DRMS
• Annual Report Year: 2016
• Email Name: ACY
• 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: Ray Anderson
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Permittee Company: Puckett Land Company
Address: 5460 S.Quebec St.,Suite 250
Greenwood Village,CO 80111 v,
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Chuck Whiteman
Company: Chuck Whiteman
Address: P,O. Box 957
Meeker,CO 81641
Phone Number: [phone]
Fax Number:
Email Address: C @rio6latteo.eemr 6 013E 4A-!�-O
Inspection Contact: jChuck Whiteman
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Company: Chuck Whiteman 1r
Address: P.O.Box 957
Meeker,CO 81641 y,
Phone Number: [phone]
Fax Number:
Email Address: Gpae#rt?riohhmcmcarri
1,the undersigned,hereby state that the information providod in this report is true and accurate,and that site operations are
being conducte 4' accordance with the Division approved mining and reclamation plans.
Signature of Permittee.Corporate Officer,Owner,or Documented Desi nee Date
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