2017-06-29_M1987097_Annual Fee Notice ARCHIVE

• Permit No: M1987097A
• IBM Index Class Name: Report
• Doc Date: 6/29/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Conejos County
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

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:

Tressesa Martinez
Permittee Company:

Conejos County
Address:

P.O. Box 157
6683 County Rd 13
Conejos, CO 81129

Phone Number:

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

Phil Esquibel
Company:

Conejos County
Address:

P.O. Box 157
6683 County Rd 13
Conejos, CO 81129

Phone Number:

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

Phil Esquibel
Company:

Conejos County
Address:

P.O. Box 157
6683 County Rd 13
Conejos, CO 81129

Phone Number:

[phone]
Fax Number: [phone]
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