2017-09-29_REPORT - M1997094

• Permit No: M1997094
• IBM Index Class Name: Report
• Doc Date: 9/29/2017
• Doc Name: Annual Fee Notice
• From: DRMS
• To: Siloam Stone, Inc.
• 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:

Ferd & Matt Mueller
Permittee Company:

Siloam Stone, Inc.
Address:

315 N. 7th St.
Canon City, CO 81212

Phone Number:

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

Stevan L. O’Brian
Company:

Environment, Inc.
Address:

7985 Vance Dr Ste 205A
Arvada, CO 80003

Phone Number:

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

Ferd & Matt Mueller
Company:

Siloam Stone
Address:

1360 Rudd Ave
Canon City, CO 81212

Phone Number:

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

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