2017-10-03_REPORT - M2004043

• Permit No: M2004043
• IBM Index Class Name: REPORT
• Doc Date: 10/3/2017
• Doc Name Note: No Signature
• Doc Name: Annual Fee/Report/Map
• From: Larry and Christine Tortorice
• To: DRMS
• Annual Report Year: 2017
• Email Name: MAC
• 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: Christine Tortorice
Permittee Company: Larry and Christine Tortorice
Address: 17512 County Road 83
Trinidad, CO 81082
Phone Number: [phone]
Fax Number:
Email Address:
iCG 3 � 9 t�►:l a c oti►
Permitting Contact: Christine Tortorice
Company: Larry and Christine Tortorice
Address: 17512 County Road 83
Trinidad,CO 81082
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Christine Tortorice
Company: Larry and Christine Tortorice
Address: 17512 County Road 83
Trinidad, CO 81082
Phone Number: [phone]
Fax Number:
Email Addr
I,the(dersigned,hereby state that the information provided in this report is true and accurate, and at site operations are
beingducted in accordance with the Division approved mining and reclamation plans.
Signat a of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01
6 IN
J � I