2017-09-28_REPORT - M2010043

• Permit No: M2010043
• IBM Index Class Name: REPORT
• Doc Date: 9/28/2017
• Doc Name: Annual Fee/Report/Map
• From: Chamberlain Concrete
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Mason Chamberlain
Permittee Company: Chamberlain Concrete
Address: 36415 U. S. Highway 385
PO Box 425
Wray, CO 80758
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Mason Chamberlain
Company: Chamberlain Concrete
Address: 36415 U.S. Hwy 385
P 0 Box 425
Wray, CO 80758
Phone Number: [phone]
Fax Number:
Email Address:
Inspection Contact: Mason Chamberlain
Company: Chamberlain Concrete
Address: 36415 U.S. Hwy 385
P 0 Box 425
Wray,CO 80758
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 accordanc 'th the Division approved mining and reclamation plans.
9 - za -17
Signature of
\I) 0/1.3V\
mittee,Corporate Officer,Owner,or Documented Designee Date
M-AF-0 1