2016-11-28_REPORT - M1983176

• Permit No: M1983176
• IBM Index Class Name: REPORT
• Doc Date: 11/28/2016
• Doc Name: Annual Fee/Report/Map
• From: Asphalt Specialties Co., Inc.
• To: DRMS
• Annual Report Year: 2016
• Email Name: ECS
• Media Type: D
• Archive: No

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Page 5 of 5
Division records indicate the following permittee/landowner 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: Rob Laird
Permittee Company: Asphalt Specialties Co., Inc.
Address: 10100 Dallas St.
Henderson, CO 80640
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Rob Laird
Company: Asphalt Specialties Co., Inc.
Address: 10100 Dallas St.
Henderson, CO 80640
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Rob Laird
Company: Asphalt Specialties Co., Inc.
Address: 10100 Dallas St.
Henderson, CO 80640
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.
Ob /A-30 201L
Signature of Permittee,Corporate Officer,Owner,or Documented Designee ffate
M-AF-01