2017-10-19_REPORT - M2000089

• Permit No: M2000089
• IBM Index Class Name: REPORT
• Doc Date: 10/19/2017
• Doc Name Note: Annual Report
• Doc Name: Annual Fee/Report/Map
• From: Mary Vasquez
• To: DRMS
• Annual Report Year: 2017
• Email Name: AME
• 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: Mary Vasquez
Permittee Company: Mary Vasquez
Address: P 0 Box 938
Lyons, CO 80540-0938
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Mary Vasquez
Company: Mary Vasquez
Address: 3587 Stone Canyon Rd.
P.O. Box 938
Lyons, CO 80540
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact: Mary Vasquez
Company: Mary Vasquez
Address: 3587 Stone Canyon Rd.
P.O. Box 938
Lyons, CO 80540
Phone Number: [phone]
Fax Number:
Email Address: [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.
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Signature of Permitee, Corp a-eer,Owner,or Documented Designee Date
M-AF-01