2017-10-11_REPORT - M1981013

• Permit No: M1981013
• IBM Index Class Name: REPORT
• Doc Date: 10/11/2017
• Doc Name: Annual Fee/Report/Map
• From: Nichols Gravel
• To: DRMS
• Email Name: SJM
• 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: John Nichols
Permittee Company: Nichols Gravel Pit,L.L.P.
Address: P.O. Box 285
Mesa,CO 81643
Phone Number: [phone]
Fax Number: [phone]
Email Address: h t L ko 14.J;,kA 7-33 & yak,o e o-m
Permitting Contact: John Nichols
Company: Nichols Gravel Pit, L.L.P.
Address: P.O.Box 285
Mesa,CO 81643
Phone Number: [phone]
Fax Number: 17O Lb 8�"
Email Address:
Inspection Contact: John Nichols
Company: Nichols Gravel Pit,L.L.P.
Address: P.O. Box 285
Mesa,CO 81643
Phone Number: [phone]
Fax Number: 5"6 ��
Email Address: 64nf A-3,
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.
9( (41, ku �717-Ylr 7
Signature I
Permittee,Corporate Officer,Owner,or Documented Desianee Date
M-AF-01