2017-09-29_M2013028_Annual Fee Notice ARCHIVE

• Permit No: M2013028A
• IBM Index Class Name: Report
• Doc Date: 9/29/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Western States Minerals,LLC
• 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:

Randy Burks
Permittee Company:

Western States Minerals,LLC
Address:

7964 E. Homestead Rd.
Parker, CO 80138

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact:

Jeff Vogt
Company:

Address:

1260 Eudora St.
Denver, CO 80220

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact:

Randy Burks
Company:

Western States Minerals,LLC
Address:

7964 E. Homestead Rd.
Parker, CO 80138

Phone Number:

[phone]
Fax Number:
Email Address: [e-mail]

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-02