2017-11-30_REPORT - M2006039

• Permit No: M2006039
• IBM Index Class Name: Report
• Doc Date: 11/30/2017
• Doc Name: Annual Fee/Report/Map
• From: Chevron Shale Oil Company, a division of Chevron USA, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: ACY
• 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 infonnation is blank or not current, please type or print current contact information:
Permittee Contact:
Permittee Company:
Vince Guinta
Michael Haub
Chevron Shale Oil Company, a
division of Chevron USA, Inc.
_
Address:
760 Horizon Drive Suite 412
Grand Junction. CO 81506
100 Chevron Road, Suite 102
Rangely, CO 81648
Phone Number:
[phone]
(970)-657-3814
Fax Number:
[phone]
(970)-657-3800
[e-mail]
Email Address:
Gavj((i chevron.com
Permitting Contact:
Michael Haub
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact:
Michael Haub
Company:
Address:
Phone Number:
Fax Number:
Email Address:
1, 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.
11/30/2017
Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date
%I- 4 F -0I