2017-07-26_M2010043_Annual Fee Notice ARCHIVE

• Permit No: M2010043A
• IBM Index Class Name: Report
• Doc Date: 7/26/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Chamberlain Concrete
• Annual Report Year: 2017
• Media Type: D
• Archive: Yes

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:

Mason Chamberlain
Permittee Company:

Chamberlain Concrete
Address:

36415 U. S. Highway 385
P O Box 425
Wray, CO 80758

Phone Number:

[phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact:

Mason Chamberlain
Company:

Chamberlain Concrete
Address:

36415 U.S. Hwy 385
P O Box 425
Wray, CO 80758

Phone Number:

[phone]
Fax Number:
Email Address:
Inspection Contact:

Mason Chamberlain
Company:

Chamberlain Concrete
Address:

36415 U.S. Hwy 385
P O Box 425
Wray, CO 80758

Phone Number:

[phone]
Fax Number:
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 Division approved mining and reclamation plans.

Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date
M-AF-01