2017-09-08_REPORT - M1977308

• Permit No: M1977308
• IBM Index Class Name: REPORT
• Doc Date: 9/8/2017
• Doc Name: Annual Fee/Report/Map
• From: CEMEX, Inc.
• To: DRMS
• Email Name: AME
• 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: Bradley S. Wilson
Permittee Company: CEMEX,Inc.
Address: P.O.Box 529
Lyons,CO 80540
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Steve Goodrich Ct)►�a
Company: CEMEX, Inc.
Address: P.O. Box 529
Lyons,CO 80540
Phone Number: [phone]
Fax Number:
Email Address: MSG \\,c.Jh�r�4.V\e%a49c Amoex
Inspection Contact: Monica Sowders
Company: CEMEX, Inc.
Address: P.O. Box 529
Lyons,CO 80540
Phone Number: [phone]
Fax Number:
Email Address: i U KP-@ cGw,eX•G..v
I,the undersigned,hereby state that thG information provided in thisdr-eclarnation
ort is true and accurate, and that site operations are
being conducted in accordance with the Division approved mining plans.
Bradley Shane Wilson,Plant Manager--�— L—,k -/, cl_
Signature of Permittee Corlporate O ,Owne rDaiumented Desi nee Date
M-AF-01