2017-12-21_REPORT - M2002053

• Permit No: M2002053
• IBM Index Class Name: REPORT
• Doc Date: 12/21/2017
• Doc Name: Annual Fee/Report/Map
• From: John Kurtzer
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• Media Type: D
• Archive: No

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information on record). If this information is blank or not cuntnt,please type or pant camvmt contact inform86ni:
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Address: 24463 CR 11
Haxtun,CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: John R.Kurtzer
Company: John R. Kurtzer
Address: 24463 CR 11
Haxtun, CO 80731
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: John R. Kurtzer
Company: John R. Kurtzer
Address: 24463 CR 11
Haxtun, CO 80731
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.
SigFt ture of Permittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-01