2017-07-11_REPORT - M1979089

• Permit No: M1979089
• IBM Index Class Name: REPORT
• Doc Date: 7/11/2017
• Doc Name: Annual Fee/Report/Map
• From: GJ Pipe & Supply
• To: DRMS
• Annual Report Year: 2016
• Email Name: SJM
• 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 81501-
3826
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Jon Mueller
Company: Grand Junction Pipe& Supply
Co.
Address: 556 Struthers Ave.
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:
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 th ivision ap r ed mining and reclamation plans.
Signature of Per tee Cor orate ffic ,Owner'.or Documented Designee Date
M-AF-O I