2016-12-16_REPORT - M1981243

• Permit No: M1981243
• IBM Index Class Name: Report
• Doc Date: 12/16/2016
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Grand Junction Concrete Pipe Co.
• Annual Report Year: 2017
• Media Type: D
• Archive: No

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:

Russell A. Larsen
Permittee Company:

Grand Junction Concrete Pipe
Co.

Address:

556 Struthers Ave.
Grand Junction, CO 81501-
3826

Phone Number:

[phone]
Fax Number: [phone]
Email Address:
Permitting Contact:

Jon Mueller
Company:

Grand Junction Concrete Pipe
Co.

Address:

556 Struthers Ave
Grand Junction, CO 81502

Phone Number:

[phone]
Fax Number:
Email Address:
Inspection Contact:

Jon Mueller
Company:

Grand Junction Concrete Pipe
Co

Address:

556 Struthers Ave.
Grand Junction, CO 81501-
3826

Phone Number:

[phone]
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.

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date
M-AF-01