2017-09-20_REPORT - M1981058 ‎(2)‎

• Permit No: M1981058
• IBM Index Class Name: REPORT
• Doc Date: 9/20/2017
• Doc Name: Annual Fee/Report/Map
• From: Thomas & Ginger Latham
• To: DRMS
• Annual Report Year: 2017
• Email Name: SJM
• Media Type: D
• Archive: No

• 1
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: Josephine Bassi ac,-c a n a ae,
Permittee Company: Josephine Bassi
Address: 2046 Lake Ave
Pueblo,, CO 81004 L4 6 L-, Ir p AVe n a�
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Phone Number: [phone] � '� � i I ^ 0 5 ,
Fax Number: .7 r Q '�� u _ 2 3
Email Address: [e-mail] I l '�/q -1���. �1 �,/y ,
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Permitting Contact: Josephine Bassi
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Company: Josephine Bassi
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Address: 2046 Lake Ave
Pueblo,CO 81004 ���} c. L ke—
pa'�t"I" (�:'c
Phone Number: [phone]
Fax Number: / 2-3 P
Email Address: [e-mail]
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Inspection Contact: Josephine Bassi
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Company: Josephine Bassi
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Address: 2046 Lake Ave _ 1�
Pueblo„ CO 81004 O �--���`�- ve-4 ae-
Phone Number: [phone] 7/
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Fax Number: -71 q
Email Address: [e-mail]
I,the undersigned,hereby state that the information provided in this report is true and accurate, and that site op ions are
being conducted in accordance with the Division approved mining and reclamation plans.
6R. L41X�g5t� - q- I 17
Signature of Permittee,Corporate Officer,Owner,G Documented Designee Date
M-AF-01