2017-07-27_REPORT - M2001052

• Permit No: M2001052
• IBM Index Class Name: REPORT
• Doc Date: 7/27/2017
• Doc Name: Annual Fee/Report/Map
• From: Kit Carson County
• To: DRMS
• Annual Report Year: 2016
• Email Name: ERR
• 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: Dave Hornung
Permittee Company: Kit Carson County
Address: P O Box 160
Burlington, CO 80807
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Dave Hornung
Company: Kit Carson County
Address: P O Box 160
Burlington, CO 80807
Phone Number: [phone]
Fax Number:
Email Address: Dnr—[e-mail]
Inspection Contact: Dave Hornung
Company: Kit Carson County
Address: P O Box 160
Burlington, CO 80807
Phone Number: [phone]
Fax Number:
Email Address: Dnr—[e-mail]
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,Corno fficer,Owner,or Documented Designee Date
M-AF-01