2017-11-02_REPORT - M1997065

• Permit No: M1997065
• IBM Index Class Name: Report
• Doc Date: 11/2/2017
• Doc Name: Annual Fee/Report/Map
• From: LJS, LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: JLE
• 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:
Jim Striggow
Permittee Company:
US, LLC
Address:
4717 Bay View Drive
Fort Collins, CO 80526
Phone Number:
[phone]
Fax Number:
Email Address:
[e-mail]
Permitting Contact:
Jim Striggow
Company:
US, LLC
Address:
4717 Bay View Drive
Fort Collins, CO 80526
Phone Number:
(70) 221-1832
Fax Number:
Email Address:
[e-mail]
Inspection Contact:
Jim Striggow
Company:
US, LLC
Address:
4717 Bay View Drive
Fort Collins, CO 80526
Phone Number:
(70) 221-1832
Fax Number:
Email Address:
[e-mail]
1, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in accance with the Division approved mining and reclamation plans.
ww-jk;�—
%I -AF
Owner, or Documented Desienee
Date