2017-12-07_REPORT - M2003092

• Permit No: M2003092
• IBM Index Class Name: REPORT
• Doc Date: 12/7/2017
• Doc Name: Annual Fee/Report/Map
• From: Nick H. Gray
• To: DRMS
• Annual Report Year: 2017
• Email Name: DMC
• 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: Nick H.Gray
Permittee Company: Nick H. Gray
Address: 584 65.30 Rd.
Montrose,CO 81401
Phone Number: [phone]
Fax Number:
Email Address:
Permitting Contact: Timothy M. Scanlon
Company: TMS Consulting
Address: 46125 County Road T
P.O. Box 53
Saguache,CO 81149
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Nick H. Gray
Company: Nick H. Gray
Address: 584 65.30 Rd.
Montrose,CO 81401
Phone Number: [phone]
Fax Number:
Email Address:
I,the undersigned,hereby state at the information provided in this report is true and accurate,and that site operations are
being conducted yrrr accordanc- ith the Division approved mining and reclamation plans.
ignat e of ;ermitteg, orpora • : leer,Owner,or Documented Designee Da e
M-AF-01