2017-06-29_REPORT - M1982129

• Permit No: M1982129
• IBM Index Class Name: Report
• Doc Date: 6/29/2017
• From: DRMS
• To: L. Otto Goemmer
• 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:

Jacque Goemmer
Permittee Company:

L. Otto Goemmer
Address:

P.O. Box 165
La Veta, CO 81055

Phone Number:

[phone]
Fax Number:
Email Address:
Permitting Contact:

Jacque Goemmer
Company:

L. Otto Goemmer
Address:

P.O. Box 165
La Veta, CO 81055

Phone Number:

[phone]
Fax Number:
Email Address:
Inspection Contact:

Jacque Goemmer
Company:

L. Otto Goemmer
Address:

P.O. Box 165
La Veta, CO 81055

Phone Number:

[phone]
Fax Number:
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-AF-01