2017-07-18_REPORT - M2006053

• Permit No: M2006053
• IBM Index Class Name: REPORT
• Doc Date: 7/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Canyon Rim Stone
• 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: Florence Jackson
Permittee Company: Canyon Rim Stone,LLC
Address: 27500 CR 183
Kim, CO 81049
Phone Number: [phone]
Fax Number: [phone]
Email Address. [e-mail]
Permitting Contact: Jack Clark PhD
Company: Clark Mining Services,LLC
Address: 6052 S.Newport St.
Centennial, CO 80111
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Everett Jackson Jr
Company: Canyon Rim Stone, LLC
Address: 27500 CR 183
Kim, CO 81049
Phone Number:
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 of Permittee or orate Officer,Owner,or Documelfited Designee Date
M-AF-01