2017-06-29_REPORT - M1978267

• Permit No: M1978267
• IBM Index Class Name: Report
• Doc Date: 6/29/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Otero County
• 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:

Lex Nichols
Permittee Company:

Otero County
Address:

13 West 3rd St., Room 208
La Junta, CO 81050

Phone Number:

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

Lex Nichols
Company:

Otero County
Address:

13 W. 3rd St., Ste. 208
La Junta, CO 81050

Phone Number:

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

Company:

Address:

Phone Number:

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-04