2017-12-04_REPORT - M1991147

• Permit No: M1991147
• IBM Index Class Name: REPORT
• Doc Date: 12/4/2017
• Doc Name: Annual Fee/Report/Map
• From: Belvedere Stone, LLC
• 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: William G.Johannsen
Permittee Company: Belvedere Stone, LLC
Address: C/o Ms. Ginny Kenley eno tZL.A
2635 Steel Dr -1 5 S-rib�- p F
Colorado Springs, CO 80907 ,v,fsG*4J
6 A SS
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: William G.Johannsen
Company: Belvedere Stone, LLC
Address: 2635 Steel Dr ;, 7 r 5 ST&e`- ,prat u
Colorado Springs, CO 80907
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: William G. Johannsen
Company: Belvedere Stone, LLC
Address: 2635 Steel Dr STMe4— 0 2 .
Colorado Springs, CO 80907
Phone Number: (719)35 HH90 cog 1 . -2 6 7 5 q 9
Fax Number: (-719� `f7 (—C1 3
Email Address:
rL L. pMA7tI-5('-W LC S14'AJ10.
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.
Signature of Permmi a Corporate Officer,Owner,or Documented Designee Date
M-AF-01