2017-09-18_REPORT - M2004036

• Permit No: M2004036
• IBM Index Class Name: REPORT
• Doc Date: 9/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Mason King
• To: DRMS
• Annual Report Year: 2016
• Email Name: ECS
• 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: Mason A. King
Permittee Company: Mason King
Address: P.O. Box 68
Cope, CO 80812
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Randy Schafer
Company: Consultant
Address: 40586 CR 21
Haxtun, CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Mason A. King
Company: Mason King
Address: P.O. Box 68
Cope, CO 80812
Phone Number: [phone]
Fax Number: [phone]
Email Address:
1,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in accordance wit e Division approved mining and reclamation plans.
SignaturA of Permittee,Corporate QVricer,Owner,or Documented Designee Date
M-AF-0I