2017-07-13_REPORT - M1981086

• Permit No: M1981086
• IBM Index Class Name: REPORT
• Doc Date: 7/13/2017
• Doc Name: Annual Fee/Report/Map
• From: N Colo Water Conservancy Dist.
• To: DRMS
• Annual Report Year: 2016
• Email Name: PSH
• 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: Jim Struble
Permittee Company: N Colo Water Conservancy Dist.
Address: 220 Water Avenue
Berthoud, CO 80513
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Jim Struble
Company: N Colo Water Conservancy Dist.
Address: 220 Water Avenue
Berthoud,CO 80513
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Jerry A. Westbrook
Company: N Colo Water Conservancy Dist.
Address: P.O. Box 679
Loveland, CO 80539
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 mit a Co r ora icer,Owner,or Documented Designee Date
M-AF-04