2017-09-22_GENERAL DOCUMENTS - M1989052

• Permit No: M1989052
• IBM Index Class Name: General Documents
• Doc Date: 9/22/2017
• Doc Name Note: Disbursement document request
• Doc Name: Disbursement document request
• From: Acme Brick Company
• To: DRMS
• Email Name: BJC
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the folIowing 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:
Robert Tibbetts
Permittee Company:
Acme Brick Company
Address:
401 Prairie Hawk Drive
Castle Rock, CO 80109
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
Permitting Contact:
Robert Tibbetts
Company:
Acme Brick Company
Address:
401 Prairie Hawk Dr.
Castle Rock, CO 80109
Phone Number:
[phone]
Fax Number:
Email Address:
Inspection Contact:
Robert Tibbetts
Company:
Acme Brick Company
Address:
401 Prairie Hawk Dr.
Castle Rock, CO 80109
Phone Number:
[phone]
Fax Number:
Email Address:
1, 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- I