2017-07-11_REPORT - M2002068

• Permit No: M2002068
• IBM Index Class Name: REPORT
• Doc Date: 7/11/2017
• Doc Name: Annual Fee/Report/Map
• From: Rick Ensminger
• To: DRMS
• Annual Report Year: 2016
• Email Name: ERR
• 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: Rick Ensminger
Permittee Company: Rick Ensminger
Address: P.O.Box 276
Haxtun,CO 80731
Phone Number: [phone] D,*7Ys'1c� �10 Z-10 r ©-.i 0 S Fax Number:Number: [phone]
Email Address:
Permitting Contact: Randy Schafer
Company: Randy Schafer
Address: 40586 CR 21
Haxtun,CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Rick Ensminger
Company: Rick Ensminger
Address: P.O.Box 276
Haxtun,CO 80731
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.
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Signature of Permtttee.Cornorate Officer, r,or Documented Designee Date
M-AF-01