2017-11-03_REPORT - M1977443

• Permit No: M1977443
• IBM Index Class Name: Report
• Doc Date: 11/3/2017
• Doc Name: Annual Fee/Report/Map
• From: Northwest Aggregates, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: GRM
• Media Type: D
• Archive: No

Page 5 of
Division records indicate the following permittee/landowner contact information (blank fields indicate that we do mot have
information on record). If this information is blank or not current,please type or -print current contact informatiam
Permittee Contact:
Russell A- Larsen
Permittee Company:
Northwest Aggregates, Inc_
Address:
556 Struthers Ave
Grand Junction, CO 81501-
3826
Phone Number:
[phone]
Fax Number:
Email Address:
Dnr—[e-mail]
Permitting Contact:
Russell A. Larsen
Company:
Northwest Aggregates, Inc.
Address:
556 Struthers Ave
Grand Junction, CO 81501-
3826
Phone Number:
[phone]
Fax Number:
Email Address:
Dnr [e-mail]
Inspection Contact:
Jon Muelller
Company:
Northwest Aggregates, Inc.
Address:
556 Struthers Ave
Grand Junction, CO 81501-
3826
Phone Number:
[phone]
Fax Number:
Email Address:
Dnr—[e-mail]
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 apprqyr)d mining and reclamation plans.
Signature of
\1 Ar E
, Owner, or Documented Designee
zb
Date