2017-12-19_REPORT - M2007012

• Permit No: M2007012
• IBM Index Class Name: REPORT
• Doc Date: 12/19/2017
• Doc Name: Annual Fee/Report/Map
• From: Gregory Larson
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Gregory Larson
Permittee Company: Gregory Larson
Address: 14977 Co. Rd. 97
Haxtun, CO 80731
Phone Number: [phone]
Fax Number:
Email Address:
Permitting Contact: Randy Schafer
Company: Randy Schafer
Address: 40586 CR 21
Haxtun, CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Gregory Larson
Company: Gregory Larson
Address: 14977 Co. Rd. 97
Haxtun, CO 80731
Phone Number: [phone]
Fax Number:
Email Address:
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 ith the Division approved mining and reclamation plans.
Signature P ittee Corporate Officer,Owner,or Documented Designee Date
M-AF-01