2017-08-02_REPORT - M2004037

• Permit No: M2004037
• IBM Index Class Name: REPORT
• Doc Date: 8/2/2017
• Doc Name: Annual Fee/Report/Map
• From: John M. Everitt
• 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: John M.Everitt
Permittee Company: John M.Everitt
Address: 24274 CR 17
Haxtun,CO 80731
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: John M.Everitt
Company: John M.Everitt
Address: 24274 CR 17
Haxtun,CO 80731
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: John M.Everitt
Company: John M.Everitt
Address: 24274 CR 17
Haxtun,CO 80731
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 rdance with the Division approved mining and reclamation plans.
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S4&fire of Permittm-&-nmrate figficer Owner.or Documented Designee Date
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