2017-10-31_REPORT - M1992060

• Permit No: M1992060
• IBM Index Class Name: Report
• Doc Date: 10/31/2017
• Doc Name: Annual Fee/Report/Map
• From: City of Monte Vista
• To: DRMS
• Annual Report Year: 2017
• Email Name: THM
• 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:
Forrest Neuerburg
Permittee Company:
City of Monte Vista
Address:
95 W, 1st
Monte Vista, CO 81144
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
[e-mail]
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Permitting Contact:
Tony Martinez
Company:
City of Monte Vista
Address:
4 Chico Camino
Monte Vista, CO 81144
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Phone Number:
[phone]
7/9- o q2_
Fax Number:
?/ g C65
Email Address:
Inspection Contact:
Tony Martinez
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Company:
City of Monte Vista
Address:
4 Chico Camino
Monte Vista, CO 81144
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Phone Number:
[phone]
Fax Number:
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 accordance with the Division approved mining and reclamation plans.
Signature or Permittee Corporate Offi er, Owner, or Documented Designee ate
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