2017-10-18_REPORT - M1991074

• Permit No: M1991074
• IBM Index Class Name: REPORT
• Doc Date: 10/18/2017
• Doc Name: Annual Fee/Report/Map
• From: Kiowa County
• To: DRMS
• Annual Report Year: 2017
• Email Name: AME
• Media Type: D
• Archive: No

Page SofS
Division rezan'indicate the flallftwinz pPn?ittoelrdn-wneT.contactinfrripat=a- -(1111.-1 fields indicate that we have
information on record). If this information is blank or not current,please type or print current contact information:
I + matin- liadc_H
Address: P.O.Box 100
_ Eads,CO 81036 =
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company: Kiowa County
Address: P.O. Box 100
1305 Goff St
Eads, CO 81036
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact:
Company: Kiowa County
Address: P.O.Box 100
1305 Goff St
Eads, CO 81036
Phone Number: [phone]
Fax Number: [phone]
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 cordance with the Division approved mining and reclamation plans.
/ L' �l
71/70e---1— / 0 //117
Signatu a Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-04