2017-11-24_REPORT - M1985112

• Permit No: M1985112
• IBM Index Class Name: REPORT
• Doc Date: 11/24/2017
• Doc Name: Annual Fee/Report/Map
• From: Loloff Construction, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• 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: Kelly Hodge
Permittee Company: Loloff Construction,Inc.
Address: 801 8th Street,Suite 130
Greeley,CO 80631
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact:
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Company:
Address: 30 j DLy�=/4 6/e c ,r&ff
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Phone Number:
Fax Number:
Email Address:
Inspection Contact: Kelly Hodge
Company: /‘�l'� ,/11/l�//2'
Address: 801 8th Street, Suite 130
Greeley,CO 80631
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
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 ►'vision approved mining and reclamation plans.
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Sid j ure of Per AntiTrairfrate er,or Documented Designee Date
M-AF-01