2017-12-19_REPORT - M2004048

• Permit No: M2004048
• IBM Index Class Name: REPORT
• Doc Date: 12/19/2017
• Doc Name: Annual Fee/Report/Map
• From: Robert Daugherty
• To: DRMS
• Annual Report Year: 2017
• Email Name: LJW
• 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: Robert Daugherty
Permittee Company: Robert Daugherty
Address: P.O. Box 1364
Clifton, CO 81520
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Gerald J.Daub
Company: Daub&Associates, Inc.
Address: 1985 1/2 South Broadway
Grand Junction, CO 81503
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Robert Daugherty
Company: Robert Daugherty
Address: P.O. Box 1364
Clifton, CO 81520
Phone Number: [phone]
Fax Number: [phone]
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 with the Division approved mining and reclamation plans.
let A4,2
A'
Signature of Permi t a torwWate Officer,Owner,or Documented Designee ate
M-AF-01