2017-11-16_REPORT - M1981154

• Permit No: M1981154
• IBM Index Class Name: Report
• Doc Date: 11/16/2017
• Doc Name: Annual Fee/Report/Map
• From: San Miguel County
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• Media Type: D
• Archive: No

Page 5 ofS
133ivision records indicate the'following permitteellandowner contact information(blank Tieldsindicate 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: Mike HomI -Y,¢4/ 0164/Cr7-7
Permittee Company: San Miguel County
Address: P.O. Box 426
Norwood,CO 81423
Phone Number: [phone]
Fax Number: [phone]
Email Address:
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Permitting Contact: Mike Homer
Company: San Miguel County
Address: P.O. Box 426
Norwood,CO 81423
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Mike Homer i{g 777
Company: San Miguel County
Address: P.O. Box 426
Norwood,CO 81423
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.
7itc-l- // /
Signa u Permit./Cor fora te Officer,Owner,or Documented Designee a e
M-AF-04