2017-01-17_REPORT - M2006039

• Permit No: M2006039
• IBM Index Class Name: REPORT
• Doc Date: 1/17/2017
• Doc Name: Annual Fee/Report/Map
• From: Chevron Shale Oil Company
• To: DRMS
• Annual Report Year: 2017
• Email Name: ACY
• 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: Julie Justus V-nc.r—
Permittee Company: Chevron Shale Oil Company,a
division of Chevron USA, Inc.
Address: 760 Horizon Drive Suite 412
Grand Junction,CO 81506
Phone Number: [phone] Cl i D ASS 3 w 1 z 3
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
Inspection Contact:
Company:
Address:
Phone Number:
Fax Number:
Email Address:
1,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.
Sign ture of Permittee.Corporate Officer,Owner,or Documented Designee Date
M-AF-01