2017-06-29_REPORT - M1979097

• Permit No: M1979097
• IBM Index Class Name: Report
• Doc Date: 6/29/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: City of Fort Collins
• Annual Report Year: 2017
• 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:

Donnie Dustin
Permittee Company:

City of Fort Collins
Address:

700 Wood Street
P.O. Box 580
Fort Collins, CO 80522

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact:

Company:

Address:

Phone Number:

Fax Number:
Email Address:
Inspection Contact:

Donnie Dustin
Company:

Address:

700 Wood Street
P.O. Box 580
Fort Collins, CO 80522

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]

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-AF-04