2017-10-12_REPORT - M2016022

• Permit No: M2016022
• IBM Index Class Name: REPORT
• Doc Date: 10/12/2017
• Doc Name: Annual Fee/Report/Map
• From: Arnolds Custom Seeding
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• 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: Rick Gillan
Permittee Company: Arnolds Custom Seeding,LLC
Address: 4626 CR 65
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr—[e-mail]
Permitting Contact: Darren Dever
Company: Arnolds Custom Seeding, LLC
Address: 4626 CR 65
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr—[e-mail]
Inspection Contact: Rick Gillan
Company: Arnolds Custom Seeding, LLC
Address: 4626 CR 65
Keenesburg, CO 80643
Phone Number: [phone]
Fax Number: [phone]
Email Address: Dnr—[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.
Signat re of Permittee Corporate fficer,Owner,or Documented Desienee Dat
M-AF-0