2017-08-08_REPORT - M2014017

• Permit No: M2014017
• IBM Index Class Name: REPORT
• Doc Date: 8/8/2017
• Doc Name: Annual Fee/Report/Map
• From: Mark Krivanek
• To: DRMS
• Annual Report Year: 2017
• 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: Mark Krivanek
Permittee Company: Mark Krivanek
Address: 101 F Street
Salida, CO 81201
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Mark Krivanek
Company: Mark Krivanek
Address: 101 F Street
Salida,CO 81201
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Mark Krivanek
Company: Mark Krivanek
Address: 101 F Street
Salida, CO 81201
Phone Number: [phone]
Fax Number: [phone]
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 ' ith the Division approved mining and reclamation plans.
4-1( -•
(Sig .t • of Permittee,Corp i .:te Officer,Owner,or Documented Designee I•te
M- ,-02