2016-12-28_REPORT - M2009035

• Permit No: M2009035
• IBM Index Class Name: REPORT
• Doc Date: 12/28/2016
• Doc Name: Annual Fee/Report/Map
• From: M.A. Concrete Construction, Inc.
• To: DRMS
• Annual Report Year: 2016
• Email Name: SJM
• 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: Martin Azcarraga
Permittee Company: M.A. Concrete Construction,
Inc.
Address: 2323 River Road
Grand Junction, CO 81505
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Martin Azcarraga
Company: MA Concrete Construction Inc.
Address: 2323 River Road
Grand Junction, CO 81505
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Martin Azcarraga
Company: MA Concrete Construction Inc.
Address: 2323 River Road
Grand Junction, CO 81505
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.
Signature of Cor orate Officer,Owner,or Documented Designee Date
M-AF-01