2017-09-18_REPORT - M1981309

• Permit No: M1981309
• 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 King
Permittee Company: Mason King
Address: P.O. Box 68
Cope, CO 80812
Phone Number: [phone]
Fax Number:
Email Address:
Permitting Contact: Mason King
Company: Mason King
Address: P.O. Box 68
Cope, CO 80812
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact:
Company:
Address:
Phone Number:
Fax Number:
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 wA the Division approved mining and reclamation plans.
0� e- 3'o-1 7
Signature o Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-04