2017-02-17_REPORT - M1979045

• Permit No: M1979045
• IBM Index Class Name: REPORT
• Doc Date: 2/17/2017
• Doc Name: Annual Fee/Report/Map
• From: Lakewood Brick & Tile
• To: DRMS
• Annual Report Year: 2017
• Email Name: MAC
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following per►nittee/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: Thomas J. Murray
Permittee Company: The Lakewood Brick and Tile
Company
Address: 1325 Jay St
Lakewood,CO 80214-2052
Phone Number: [phone]
Fax Number: [phone]
Email Address: Tmurray(c�'summitbrick.com
Permitting Contact: James R. Murray Tom Murray
Company: The Lakewood Brick and Tile
Company
Address: 1325 Jay St
Denver,CO 80215
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact: James R. Murray Tom Murray
Company: The Lakewood Brick and Tile
Company
Address: 1325 Jay St
Denver,CO 80215
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
1, the undersigned, hereby state that the in ormation provided in this report is true and accurate, and that site operations are
being conduct in accord cc ith tl ivision approved mining and reclamation plans.
/ A5,D i,-A 2 I6 Zi
Sign ure of PermitKe,Cor o ate Offi r,Owner,or Documented Designee Date