2017-12-05_REPORT - M2006060

• Permit No: M2006060
• IBM Index Class Name: REPORT
• Doc Date: 12/5/2017
• Doc Name: Annual Fee/Report/Map
• From: Jackson County
• 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: Andy Norris
Permittee Company: Jackson County
Address: P.O. Box 488
Walden, CO 80480
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Andy Norris
Company: Jackson County Road and
Bridge
Address: 188 Grant St.
P.O. Box 488
Walden, CO 80480
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Andy Norris
Company: Jackson County Road and
Bridge
Address: 188 Grant St.
P.O. Box 488
Walden, CO 80480
Phone Number: [phone]
Fax Number: [phone]
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.
Signature of Pekhittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-04