2017-07-18_REPORT - M1997035

• Permit No: M1997035
• IBM Index Class Name: REPORT
• Doc Date: 7/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Park County
• To: DRMS
• Annual Report Year: 2016
• 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:
►J i K� G r� n
Permittee Company: Park County
Address: P.O. Box 147
Fairplay, CO 80440
Phone Number: - —I`a .
Fax Number: [phone]
Email Address: r 1 ( r ,/ c ` L)
Permitting Contact: uQ-14r-aa Q.Q-ke 1_
Company: Park County
Address: P.O. Box 147
1246 County Road 16
Fairplay,CO 80440
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: -ems- � \i , _• n ��
Company: Park County
Address: P.O. Box 147
1246 County Road 16
Fairplay, CO 80440
Phone Number: [phone]
Fax Number: [phone]
Email Address:
1,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.
�&A 171'a- X1?
Signature of Pe ittee CUkiforate Officer,Owner,or Documented Designee Date
M-AF-04