2018-04-02_REPORT - M2014041

• Permit No: M2014041
• IBM Index Class Name: REPORT
• Doc Date: 4/2/2018
• Doc Name Note: Missing Signature Page Enclosed
• Doc Name: Annual Fee/Report/Map
• From: Russel Painter
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• Media Type: D
• Archive: No

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Division records indicate the following permittee/landow er 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:
Permittee Cempany:
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Address:
Phone Number:
Fax Number:
Email Address:
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact:
Company:
Address:
Phone Number:
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 with the Division approved mining and reclamation plans.
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Signature o ermi ee,Coraorate icer,Owner,or Do-&V&nted Designee Date
M-AF-01
PF.Id CR.due date