2017-07-27_REPORT - M1983209

• Permit No: M1983209
• IBM Index Class Name: REPORT
• Doc Date: 7/27/2017
• Doc Name: Annual Fee/Report/Map
• From: Frank Gilmore
• To: DRMS
• Annual Report Year: 2016
• Email Name: SJM
• 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: Frank Gilmore
Permittee Company: Frank Gilmore
Address: 13721 G Road
Delta, CO 81416
Phone Number: [phone]
Cell 9►�o��ld-c{Zb>� ✓
Fax Number:
Email Address:
Permitting Contact: Frank Gilmore
Company: Frank Gilmore
Address: 13721 G Road
Delta, CO 81416
Phone Number: [phone]
L970) 910
Fax Number:
Email Address:
z v►�c�,Co� ✓
Inspection Contact: Frank Gilmore
Company: Frank Gilmore
Address: 13721 G Road
Delta, CO 81416
Phone Number: [phone]
el( t-1
Fax Number:
Email Address: raC1�,1 .Z J�o.Can�
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.
- 17
Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01