2017-07-28_REPORT - M1984043

• Permit No: M1984043
• IBM Index Class Name: REPORT
• Doc Date: 7/28/2017
• Doc Name: Annual Fee/Report/Map
• From: Pelino, Inc
• To: DRMS
• Annual Report Year: 2016
• Email Name: DMC
• 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: Scott Pelino
Permittee Company: Pelino, Inc.
Address: P.O. Box 5049
26000 Highway 285
Buena Vista,CO 81211
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Scott Pelino
Company: Pelino, Inc.
Address: P.O. Box 5049
2�00© Vilhway ass
Buena Vista,CO 81211
Phone Number: [phone]
Fax Number: [phone]
Email Address: cowl
Inspection Contact: Scott Pelino
Company: Pelino, Inc.
Address: P.O. Box 5049
). 00<3 Ri lwo.y 2f35
Buena Vista,CO 81211 .•II
Phone Number: [phone]
Fax Number: [phone]
Email Address: n
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1,the and si ed,hereby state that the information provided in this report is true and accurate, and that site operations are
being con ed igaccordan ith the Division approved mining and reclamation plans.
_I
Signature of Permittee, orporate Officer,Owner,or Documented Designee Date
M-AF-01