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TCOLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Elewtrr.ent of Laturgl Resources <br /> 1313 Sherman Street, Room 215 <br /> Denver, CO 80203 <br /> IMAGED DOCUMENTS CD/DVD REQUEST FORM <br /> Imaged documents can be viewed and downloaded free of charge in the reception area of the DBMS offices and <br /> online at http://n ining.state.co.us/Reports/Pages/ImagedDocumentData.aspx,or they can be purchased on a CD <br /> or DVD. The CD/DVD purchase price includes costs for staff time related to data compilation and mailing <br /> costs. Data on the disk will conk%„kf y1tiap ri f f llaQ.¢tea�� .,,rA+a-••: , .,1r A � -- --n , <br /> i »:"...t a wiu i yu.a u1C'IeJC Ui t�is u4�i`1Grobat lCG•d�l1Cr IO e <br /> viewed. <br /> Please indicate the permit and/or file numbers for which you are requesting imaged documents: <br /> l} M1990-041 2} 3) 4} <br /> Please indicate your preference below and return this form with your payment to the Division. If a CD is <br /> requested and the data is too large for a CD, we will contact you. <br /> CD @$5.00 per disk(--700MB) Effn DVD @$20.00 per disk(--4.7GB) <br /> Mailing and Contact Information: <br /> Name: Matt Collins <br /> Company Name: Black Fox Mining LLC DRMS Use Only: <br /> Mailing CD/DVD created and <br /> Address: 1508 Ridge Rd. tested b <br /> (Street Address) <br /> Nederland Co 80466 <br /> (City) (State) (Zip) me) <br /> (N <br /> Daytime Phone Number: 303-570-6269 Zq <br /> D191MIly signed by Man Cdflna,P.E. ate I <br /> Signature: Matt Collins, RE E. ou,email=mcddnsabiaddoxmfn�ingiic cM--Us LLC° <br /> Oatw 202Q_04.,4 1Q,58,22--06'm' . <br /> Disclaimer: <br /> The Colorado Di,rsion of Reclamation. Alining and SaJeti'(DRMS)is nut respo,tsible ctrul.!tall nor lx licrhle to rite userfnr durnuges of <br /> arty kind arising out of the use of dales ar informalion provided by DRMS.including the in allation gfthe dales infomatian,its use, or <br /> the r•ewits uhlamuclJrum its use. Ant Bala o•informanan provided hi,DRMS i% "as is': ,vithoul anY irar rant,-of anv kind.either <br /> erpraw;or implied including but not limited to,the implied wa ranues of nnerthaniahility and fitness for a particulur pur pose. Data or <br /> ii f n-wation provided ht•the DRA1S shall he used awl relied rtpunr orrlh,at the riser's,rule risk.and the user agreev to indeninify and hold <br /> harmless DRMS,its alficials,affc•crs and einple veev.f ruin ally liabdin,arising frutnn the use of the darcuii formritio„provided <br /> DDVix,.'c,f tnnANoWMbIr2017 <br /> 1313 Sherman Street,Room 215, Denver,CO 80203 P 303.866.3567 F 303.832,8106 http.,//mining.state.co.us <br /> John W. Hickentooper, Governor l Mike King, Executive Director l Virginia Brannon, Director •`. "` <br />