2017-07-21_REPORT - M1994077

• Permit No: M1994077
• IBM Index Class Name: REPORT
• Doc Date: 7/21/2017
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ECS
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact information(blank fields indicate that we do of have
information on record). If this information is blank or not current, please type or print current contact information:
Permittee Contact: Steve Williams
Permittee Company: Washington County
Address: 150 Ash Avenue
Akron,CO 80720
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Steve Williams
Company: Washington County Dist 43
Address: P.O. Box 32
11920 County Road CC
Anton, CO 80801
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Steve Williams
Company: Washington County Dist#3
Address: P.O. Box 32
11920 County Road CC
Anton, CO 80801
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
being conducted in accordance with the Division approved mining and reclamation plans.
/'b�a-
Designee Signa re of Permittee,Corporate Officer, Owner,or Documented 7
Date
NI-AF-04