2017-09-20_REPORT - M1975009 ‎(2)‎

• Permit No: M1975009
• IBM Index Class Name: Report
• Doc Date: 9/20/2017
• Doc Name: Annual Fee/Report/Map
• From: The Lakewood Brick and Tile Company
• To: DRMS
• 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: 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:
Tom Murray
Company: The Lakewood Brick and Tile
Company
Address: 1325 Jay St
Lakewood, CO 80214
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact: WW* Tom Murray /
Company: The Lakewood Brick and Tile l/
Company
Address: 1325 Jay St
Lakewood,CO 80214
Phone Number: [phone]
Fax Number:
Email Address: [e-mail] kl
I, 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.
Signat re of Per tee Cor6orate OW11cer,Owner,or Documented Desianee Date