2017-10-03_REPORT - M1993035

• Permit No: M1993035
• IBM Index Class Name: REPORT
• Doc Date: 10/3/2017
• Doc Name: Annual Fee/Report/Map
• From: Summit County Government and Town of Breckenridge
• To: DRMS
• Annual Report Year: 2017
• 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: Brian Lorch
Permittee Company: Summit County Government and
Town of Breckenridge
Address: P.O. Box 5660
Frisco, CO 80443
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Heide Andersen
Company: Town of Breckenridge
Address: P.O. Box 168
Breckenridge, CO 80424
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Brian Lorch
Company: Summit County Government
Address: P.O.Box 5660
Frisco,CO 80443
Phone Number: [phone]
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 with t Division approved mining and reclamation plans.
31 - ,Avg� .2 S/�
Signature o e tee Cor orate Officer,Owner,or Documented Designee Date
M-AF-04