2017-08-18_REPORT - M2014061

• Permit No: M2014061
• IBM Index Class Name: REPORT
• Doc Date: 8/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Schlosser Incorporated
• 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: Levi Schlosser
Permittee Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington, CO 80807
Phone Number: [phone]
Fax Number: 7/?
f?341& _ 0$3
Email Address: [e-mail] ,
Permitting Contact: Levi Schlosser
Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington,CO 00000
Phone Number: [phone]
Fax Number: 71 f- '3 b
Email Address: [e-mail]
Inspection Contact: Levi Schlosser
Company: Schlosser Incorporated
Address: 755 Hwy 385
Burlington,CO 99990-
go�o
Phone Number: [phone]
Fax Number: f
7j?- '3 uG- ks g
Email Address: [e-mail]
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.
�/A /
Sign re of Permittee. ornorate Officer,Owner,or Documented Designee D to
M-AF-01