Laserfiche WebLink
COLORADO <br /> DRMS Complaint Intake Tool Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resources <br /> By Submitting this form you are requesting an investigation of <br /> compliance with DRMS rules. <br /> COMPLAINANT INFORMATION <br /> Date of Complaint <br /> 07/05/2018 <br /> Indicates a Required Field <br /> Do you wish to remain anonymous? <br /> r Yes r No <br /> Your First Name <br /> Doug <br /> Your Last Name <br /> Giem <br /> Your Address <br /> 400 N 12 th St <br /> Your City <br /> Canon city <br /> Your State <br /> CO <br /> Your Zip Code <br /> Maximum of 10 digits. (Example)80202 <br /> 81213 <br /> Email Address <br /> Enter a valid email address in this field to receive a confirmation e-mail and copy of your Complaint form. <br /> dggiem@gmail.com <br /> Your Phone Number* <br /> Used only to follow up. Please enter phone number in this format: (Example) 123-456-7890 <br /> 719-429-5164 <br /> Alternate Phone Number <br /> Used only to follow up. Please enter phone number in this format: (Example) 123-456-7890 <br /> Connection to Incident <br /> Select all that apply <br /> F Land Owner r Mineral Owner <br /> F Nearby Resident rJ Observed Incident <br /> F Other <br /> DESCRIPTION OF COMPLAINT <br /> (Please be as specific as possible) <br />