2019-03-12_GENERAL DOCUMENTS - M2019013

• Permit No: M2019013
• IBM Index Class Name: General Documents
• Doc Date: 3/12/2019
• Doc Name: Complaint
• From: Anonymous
• To: DRMS
• Email Name: ACY
• Email Name: THM
• Media Type: D
• Archive: No

iW COLORADO
DRMS Complaint Intake Tool Division of Reclamation,
Mining and Safety
Department of Natural Resources
By Submitting this form you are requesting an investigation of
compliance with DRMS rules.
COMPLAINANT INFORMATION
Date of Complaint
03/12/2019
Indicates a Required Field
Do you wish to remain anonymous?
r Yes r No
Your First Name
Jodilyn
Your Last Name
Romero
Your Address
3453 Grand Valley Canal Road
Your City
Clifton
Your State
CO
Your Zip Code
Maximum of 10 digits. (Example)80202
81520
Email Address
Enter a valid email address in this field to receive a confirmation e-mail and copy of your Complaint form.
[e-mail]
Your Phone Number*
Used only to follow up. Please enter phone number in this format: (Example) 123-456-7890
970-260-6525
Alternate Phone Number
Used only to follow up. Please enter phone number in this format: (Example) 123-456-7890
970-244-1515
Connection to Incident
Select all that apply
rJ Land Owner Mineral Owner
r1 Nearby Resident 12 Observed Incident
r Other
rUESCRIPTION OF COMPLAINT