2017-07-18_REPORT - M1993023

• Permit No: M1993023
• IBM Index Class Name: REPORT
• Doc Date: 7/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Moffat County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ACY
• 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:
Permittee Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address: ( � (enLs" C -. �Uw
Permitting Contact:
'►'1 )ALH—G-A o e
Company: Tda,crir,Tdnnra
Address: 15 ey- i t
1 LIP
Phone Number: -
Fax Number: 24 n r:�)
c�
Email Address:
Inspection Contact: Laea- -Eeeper -� /
Company: Moffat County V
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: (� e7 b f7 L
Email Address: i L�
I,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are
being conducted in acco ce with the Division approved mining and reclamation plans.
Signature of Permittej,Corporate Officer Owner,or Documented Designee Date
M-AY-04