2017-08-25_REPORT - M1984155

• Permit No: M1984155
• IBM Index Class Name: REPORT
• Doc Date: 8/25/2017
• Doc Name: Annual Fee/Report/Map
• From: Dolores County
• To: DRMS
• Annual Report Year: 2016
• Email Name: LJW
• 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: Michael S. Davis
Permittee Company: Dolores County
Address: P.O. Box 608
Dove Creek,CO 81324
Phone Number: [phone]
Fax Number: [phone]
Email Address: dCro q4y
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Permitting Contact: 'f�
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Company: Dolores County
Address: P.O.Box 608
Dove Creek,CO 81324-0608
Phone Number: [phone]
Fax Number: q 7o _0 7 _3 7 59
Email Address: 7
Inspection Contact: s1c,e�
Company: Dolores Counter i
Address: P.O.Box 608
Dove Creek,CO 81324-0608
Phone Number: [phone]
Fax Number: 7U - 6 77 - 575 q
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.
Signature of Permittee,Corporate Officer.Owner,or Documented Design Efate
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