2017-02-13_REPORT - M2010016

• Permit No: M2010016
• IBM Index Class Name: REPORT
• Doc Date: 2/13/2017
• Doc Name: Annual Fee/Report/Map
• From: GJ Pipe & Supply
• To: DRMS
• Annual Report Year: 2017
• Email Name: SJM
• Email Name: SDT
• 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 Pipe& Supply
Co.
Address: 556 Struthers Ave
Grand Junction, CO 81505-
3826
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Edward J. Settle
Company: Grand Junction Pipe& Supply
Co.
Address: P.O. Box 1849
Grand Junction, CO 81502
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Jon Mueller
Company: Grand Junction Pipe& Supply
Co.
Address: 556 Struthers Ave.
Grand Junction, CO 81501-
3826
Phone Number: [phone]
Fax Number: [phone]
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 Divison approved mining and reclamation plans.
Sign at of Permittee,Corp ate O ,Owner,or Documented Designee Date
WAF-0