2017-07-11_REPORT - M2000092

• Permit No: M2000092
• IBM Index Class Name: REPORT
• Doc Date: 7/11/2017
• Doc Name: Annual Fee/Report/Map
• From: City of Walsenburg
• To: DRMS
• Annual Report Year: 2017
• Email Name: MAC
• 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: Carolyn Tice _ M
� Ell
Permittee Company: City of Walsenburg
Address: 525 S Albert
Walsenburg,CO 81089
Phone Number: [phone]
Fax Number: [phone]
Email Address; Wa /1'J�I�IS /1A/ �. Ieq-1
Permitting Contact: Buck Barnhart
Company: Barnhart Agency,Inc.
Address: 212 W. 13th Street
Pueblo,CO 81003
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Hank Summers \��• n /� ,� A- f
Company: City of Walsenburg
Address: 525 S Albert
Walsenburg,CO 81089
Phone Number: [phone]
Fax:Number: [phone]
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 wi a Division approved mining and reclamation plans.
Signature of fermAtee, orate Officer,Owner,or Documented Designee Date
M-Ar-04