2017-07-28_REPORT - M1981138

• Permit No: M1981138
• IBM Index Class Name: Report
• Doc Date: 7/28/2017
• Doc Name: Annual Fee/Report/Map
• From: Baca County
• To: DRMS
• Annual Report Year: 2016
• Email Name: MAC
• 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:
Peter L. Dawson
Permittee Company:
Baca County
Address:
741 Main St.,Suite 1
Springfield, CO 81073
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
Permitting Contact:
Peter L. Dawson
Company:
Baca County
Address:
741 Main St.
Springfield, CO 81073
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
Inspection Contact:
Peter L. Dawson
Company:
Baca County
Address:
741 Main St.
Springfield, CO 81073
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
1, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in a-c5ordanice witlDivision approved mining and reclamation plans.
17 -
Signature of Permittee, Corporate Officer, Owner, or Documented Designee
AI -AF -OJ
Date