2017-07-28_REPORT - M2015024

• Permit No: M2015024
• IBM Index Class Name: REPORT
• Doc Date: 7/28/2017
• Doc Name: Annual Fee/Report/Map
• From: Haynes Excavation, Inc
• To: DRMS
• Annual Report Year: 2016
• Email Name: THM
• 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: Todd Haynes
Permittee Company: Haynes Excavation, Inc.
Address: 12696 6450 Rd
Montrose, CO 81401
Phone Number: [phone]
Fax Number:
Email Address:
Permitting Contact: Ben Miller
Company: Greg Lewicki and Associates,
PLLC
Address: 11541 Warrington Ct.
Parker, CO 80138
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Todd Haynes
Company: Haynes Excavation,Inc.
Address: 12696 6450 Road
Montrose, CO 81401
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.
Sign ture of Permittee Co'rpo-Eske Officer,Owner,or Documented Designee Date
M-AF-01