2017-07-26_REPORT - M1975009

• Permit No: M1975009
• IBM Index Class Name: Report
• Doc Date: 7/26/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: The Lakewood Brick and Tile Company
• Annual Report Year: 2017
• 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:

Thomas J. Murray
Permittee Company:

The Lakewood Brick and Tile
Company

Address:

1325 Jay St
Lakewood, CO 80214

Phone Number:

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

James R. Murray
Company:

The Lakewood Brick and Tile
Company

Address:

1325 Jay St
Lakewood, CO 80214

Phone Number:

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

James R. Murray
Company:

The Lakewood Brick and Tile
Company

Address:

1325 Jay St
Lakewood, CO 80214

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