2017-12-11_REPORT - M1994103 ‎(2)‎

• Permit No: M1994103
• IBM Index Class Name: REPORT
• Doc Date: 12/11/2017
• Doc Name: Annual Fee/Report/Map
• From: Costilla County
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• Email Name: GRM
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact infonnation(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: Mathew Valdez Christopher Rodriguez
Permittee Company: Costilla County
Address: P.O. Box 130
San Luis,CO 81152
Phone Number: [phone] [phone]
Fax Number: [phone] [phone]
Email Address: Mathew.valdez(u,)costillacounty- [e-mail]
co.gov
Permitting Contact: Elizabeth Pacheco Christopher Rodriguez
Company: Costilla County
Address: 352 Main St.
San Luis,CO 81152
Phone Number: [phone]
[phone]
Fax Number: [phone] `C800
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Email Address:
Inspection Contact: Robert Vasquez Christopher Rodriguez
Company: Costilla County
Address: P.O. Box 100
San Luis,CO 81152
Phone Number: [phone] [phone]
Fax Number:
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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 Permittee,Corporate Offic wner,or Documented Desianee Date
M-AF-(g