2017-11-06_REPORT - M1990114

• Permit No: M1990114
• IBM Index Class Name: REPORT
• Doc Date: 11/6/2017
• Doc Name: Annual Fee/Report/Map
• From: Sagauche County
• To: DRMS
• Annual Report Year: 2017
• Email Name: SJM
• 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: Randal Arredondo
Permittee Company: Saguache County
Address: P.O. Box 476
Saguache, CO 81149
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: - lien Cox'
1Zh1Q,n(IPA C,e2_.4
Company: Saguache County
Address: P.O. Box 655
Saguache, CO 81149
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: -Ellen Cox
r-VAtA rvnie,ll
Company: Saguache County
Address: P.O. Box 655
Saguache, CO 81149
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 co ucted in accordance with the Division approved mining and reclamation plans.
r) - ? I —1 7
Signat e of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-04