2017-11-30_REPORT - M1983089

• Permit No: M1983089
• IBM Index Class Name: REPORT
• Doc Date: 11/30/2017
• Doc Name: Annual Fee/Report/Map
• From: Douglas County Sand & Gravel, LLC
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• Media Type: D
• Archive: No

Page 3 of5
TJIVT5TUH ia.a,vi uo-uiuta.at uIE ivituw iiia
IAA N./tai auu Witl.l L JLLLatl IIILLH illaLIInl luawth.lii.ILJ /IIuR au.U4Q1wVi"i W.)£tuU W
information on record). If this information is blank or not current,please type or print current contact information.
1 Pcrmittce contact ) John 1
Permittee Company: Douglas County Sand&Gravel, -- --
LLC
Address: P.O. Box 966
Castle Rock, CO 80104
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: John Miner
Company: Douglas County Sand&Gravel,
LLC
Address: P.O. Box 966
Castle Rock, CO 80104
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: John Miner
Company: Douglas County Sand&Gravel,
LLC
Address: P.O. Box 966
Castle Rock,CO 80104
Phone Number: [phone]
Fax Number: [phone]
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.
e �� /� - 2/ -- /7
Signa 6 e of Permi ee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01