2017-07-05_REPORT - M2015022

• Permit No: M2015022
• IBM Index Class Name: REPORT
• Doc Date: 7/5/2017
• Doc Name: Annual Fee/Report/Map
• From: Lazy H, Inc
• To: DRMS
• Annual Report Year: 2016
• Email Name: JLE
• 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: William K. Havengar
Pe ittee Company: Lazy H Inc
Address: 34449 County Road 10
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: William K.Havengar
Company: Lazy H Inc
Address: 34449 County Road 10
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: I at'j H,gfQAd r con-,
Inspection Contact: William K.Havengar Oh.
Company: Lazy H Inc
Address: 34449 County Road 10
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: s -VA @ erzrd, cam ,S'2-J a
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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