2017-03-23_REPORT - M2002119

• Permit No: M2002119
• IBM Index Class Name: Report
• Doc Date: 3/23/2017
• Doc Name: Annual Fee/Report/Map
• From: Elam Construction, Inc.
• 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: Russell A.Larsen
Permittee Company: Elam Construction,Inc.
Address: 556 Struthers Ave
Grand Junction, CO 81501-
3826
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: John R.Elam
Company: Elam Construction,Inc.
Address: 556 Struthers Ave
Grand Junction, CO 81501
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Jon Mueller
Company: Elam Construction,Inc.
Address: 556 Struthers Ave
Grand Junction, CO 81501-
3826
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 Divisi approv mining and reclamation plans.
C:)- /,�/, �
Signature of Permitt or orate Office!/,Owner,or Documented Designee Date
-AF-o 1