2017-08-30_M2013015_Annual Fee Notice ARCHIVE

• Permit No: M2013015A
• IBM Index Class Name: Report
• Doc Date: 8/30/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Mike L. Koellner dba L&L Ready Mix
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

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:

Mike L. Koellner
Permittee Company:

Mike L. Koellner dba L&L
Ready Mix

Address:

810 South Colorado
P.O. Box 218
Haxtun, CO 80731

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Permitting Contact:

Jason A. Frost
Company:

Mike L. Koellner dba L&L
Ready Mix

Address:

900 West Denver
P.O. Box 325
Holyoke, CO 80734

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Inspection Contact:

Jason A. Frost
Company:

Mike L. Koellner dba L&L
Ready Mix

Address:

900 West Denver
P.O. Box 325
Holyoke, CO 80734

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 with the Division approved mining and reclamation plans.

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date
M-AF-01