2017-07-26_REPORT - M1977301

• Permit No: M1977301
• IBM Index Class Name: Report
• Doc Date: 7/26/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Colorado Lien Company
• Annual Report Year: 2017
• 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:

Clint Beck
Permittee Company:

Colorado Lien Company
Address:

P.O. Box 440
Rapid City, SD 57709

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact:

Shelly Erickson
Company:

Colorado Lien Company
Address:

P.O. Box 440
Rapid City, SD 57702

Phone Number:

[phone]
Fax Number:
Email Address:
Inspection Contact:

Tim Mosey
Company:

Colorado Lien Company
Address:

P.O. Box 1961
Fort Collins, CO 80522

Phone Number:

[phone]
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, Corporate Officer, Owner, or Documented Designee Date
M-AF-01