2017-05-31_REPORT - M1981080

• Permit No: M1981080
• IBM Index Class Name: REPORT
• Doc Date: 5/31/2017
• Doc Name: Annual Fee/Report/Map
• From: Tezak Stone & Aggr Supply Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: TC1
• 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: Mike A. Tezak
Permittee Company: Tezak Stone&Aggr Supply Inc
Address: 6200 CR 37
Faro PR X i�) CO 81223
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact:
Company:
Address:
Phone Number: (719), 1)1-7— 4
Fax Number: -71 1� 9Ar Z ,4k? ,'
Email Address:
Inspection Contact: Mike Tezak/ Kuo
Company: Tezak Stone&Aggr Supply Inc
Address: 6200 CR 37
GataP�ui ,�-a 81223
Phone Number: [phone]
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.
)� 1D/
Signature of Permittee Cor orate Officer,Owner,or Documented Designe lYate
M-AF-01