2017-11-30_REPORT - M2000059

• Permit No: M2000059
• IBM Index Class Name: REPORT
• Doc Date: 11/30/2017
• Doc Name: Annual Fee/Report/Map
• From: Geroux Gravel
• To: DRMS
• Annual Report Year: 2017
• Email Name: TC1
• 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: Andrew Kagan
Permittee Company: Geroux Gravel
Address: 1100 CR 160 S'SS I--rn
Westcliffe,CO 81252 ‘,L.942_34-c l Cd FSL2S L
Phone Number: [phone]
—7E3 - 563
Fax Number: (719) 783-27090 n
Email Address: [e-mail]
Permitting Contact: Darrell Geroux /1 re1/4.J (/ �
Company: Geroux Gravel �c
Address: 1100 CR 160 S S _E'(-71--14--12-
Westcliffe,
F(-71--14w2-Westcliffe,CO 81252 upe C ) 8-(;CS~Z
Phone Number: [phone] 71 -A3- 9636
Fax Number: [phone] ACS Q.—
Email Address:
Inspection Contact: Andrew Kagan
Company: Geroux Gravel
Address: 555 Ernest Ave
Westcliffe,CO 81252
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.
,wA____ /`/2,7/I
Signature of Permittee,Corpor e Officer,Owner,or Documented Designee Date
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