2017-09-08_REPORT - M1977361

• Permit No: M1977361
• IBM Index Class Name: REPORT
• Doc Date: 9/8/2017
• Doc Name: Annual Fee/Report/Map
• From: CEMEX, Inc.
• To: DRMS
• Annual Report Year: 2016
• Email Name: AME
• Media Type: D
• Archive: No

Y 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: PO Box 529
Lyons,CO 80540
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Michael L. Whitehead
Company: CEMEX, Inc.
Address: P.O.Box 529
Lyons,CO 80540
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Inspection Contact: Dennis Luke
Company: CEMEX, Inc.
Address: 13301 53rd St
Longmont,CO 80503
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
I,the undersigned,hereby state that the,information provided in th' r rt is•true and accurate, and that site operations are
being conducted in accordance with the Divisio ved min in a reclamation plans.
Bradley Shane Wilson,Plant Manager
Signature of Permittee,Corporate Office ,Owner r D cumcnted Deli nee Date
M-AF-01