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Quarry Department - Portland Plant Holcim (US) Inc. Phone 719-784-6325 <br />3500 State Hwy 120 Fax: 719-784-3470 <br />Hold m Florence, CO 81226 www.holcim.com/us <br />Pre-Blast Survey Form <br />Name: <br />C4 IYOVED <br />Address: <br />YES, I give Holcim (US) Inc. permission to access my property for the purposes of <br />conducting a pre-blast survey. <br />NO, I do not give Holcim (US) Inc. permission to access my property for the <br />purposes of conducting a pre-blast survey. - <br />Signed: <br />Date: