2017-10-31_REPORT - M1978107

• Permit No: M1978107
• IBM Index Class Name: Report
• Doc Date: 10/31/2017
• Doc Name: Annual Fee/Report/Map
• From: Montezuma County
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• Media Type: D
• Archive: No

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Uivision records indicate the following permitteellandowner contact information {blank Fields indicate that we do not bave
information on record). if this information is blank or not current, Tease type or -print current contact information:
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Permittee Company:
Montezuma County
Address:
1680 North Dolores Road
Cortez, CO 81321
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
Permitting Contact:
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Company:
Montezumh County.
Address:
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Cortez 0 113
Phone Number:
(970) 56 -$3.1-7 81,00
Fax Number:
9-]0) Sv5+`�
Email Address:
Inspection Contact:
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Company:
Montezuma County
Address:
i69 W. Mai , Street,
Cortez, CO 81321
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Phone Number:
(970) 565-6+H 9660
Fax Number:
0 -?0)_ 3.5-5252
Email Address:
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1, 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.
Owner, or Documented Designee
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Date