2017-07-18_REPORT - M1999048

• Permit No: M1999048
• 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:
Dan Miller
Permittee Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address:
[e-mail]
Permitting Contact: 11tMeere—
Dan Miller
Company:
Moffat County
Address: 1349 Reaney-Streef PO Box 667
Gmig; P- Craig, CO 81626
Phone Number: f 9�0 Q4-Q49---
[phone]
Fax Number: [phone] ✓
Email Address:
Inspection Contact: 20U=
Dan Miller
Company: Moffat County
Address: P.O.Box 667
Craig,CO 81626
Phone Number: [phone]
Fax Number: [phone]
Email Address:
I,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are
berg conducted in accordance with the Division approved mining and reclamation plans.
/'� 07/13/2017
ignature of Per ee o yorate Officer Owner.or Documented Desianee Date
M AF-M