2017-09-20_REPORT - M1975009

• Permit No: M1975009
• IBM Index Class Name: REPORT
• Doc Date: 9/20/2017
• Doc Name: Annual Fee/Report/Map
• From: Lakewood Brick & Tile
• To: DRMS
• Annual Report Year: 2016
• Email Name: MAC
• 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: Tmurray(cLsumitbrick.com
Permitting Contact: 4M.
Tom Murray
Company: The Lakewood Brick and Tile
Company
Address: 1325 Jay St
Lakewood,CO 80214
Phone Number: [phone]
Fax Number:
Email Address: Tmurray@summitbrick,com
Inspection Contact: Torn Murray , /
Company: The Lakewood Brick and Tile v
Company
Address: 1325 Jay St
Lakewood, CO 80214
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
1,the undersigned, hereby state that he information provided in this report is true and accurate,and that site operations are
being conducte in accor a e w. the Division approved mining and reclamation plans.
C6CD . qZ15 /7
Signat re of Per tee Cor rate O cer,Owner,or Documented Desienee Date