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Colorado Department of Public Health & Environment <br />Recycling Facility Annual Reporting Form <br />Reporting form must be submitted by March 1, 2014 <br />Name of Facility: Broda's Inert Fill - AI Platte Valley Pit <br />Address: 7§Mwy 85 <br />City: Pnghton <br />ZIP code: 80603 <br />Mailing Address, ame <br />N of Recycling Employees: _ <br />Contact person: atn ro a <br />Phone: <br />Email: mo enassoGates —maT com <br />Reporting Period, Calendar Year 2013 <br />Instructions <br />Save a copy of this file to your computer. Enter data and email the completed form to <br />cdphe hmrecvcline @state co.us or print and mail to: Matenals Management Group <br />CDPHE HMWMD -SW -B2 <br />4300 Cherry Creek or South <br />Denver, CO 80246 <br />Any records in our possession identified as "confidential business information" or as a "trade secret" will not be disclosed without giving the party raising the claim notice of the request and an <br />opportunity to contest the release of the information. The burden of proving that the information is protected as a trade secret is on the party raising the claim. In order to claim this protection, you <br />must meet the following requirements: <br />1. you must show that you have taken reasonable measures to protect the confidentiality of the information, and that you intend to continue to take such measures; <br />2. the information is not, and has not been, reasonably obtainable without your consent by other persons using legitimate means; <br />3. either. <br />I. you have satisfactorily shown that disclosure of the information is likely to cause substantial harm to your competitive position; or <br />Ii. the information is voluntarily submitted information and its disclosure would be likely to impair the Government's ability to obtain necessary information in the future, <br />4. no statute specifically requires disclosure of the information; and <br />5. you have to assert a claim of business confidentiality in writing. You may do so by checking the box below, adding your facility information and submitting along with your reporting forms. <br />I have read Items 1 -5 and am hereby requesting that information submitted on my Recycling Facility Reporting Forms be kept as confidential information <br />❑ Yes. IBOa MUST be checked to claim privilege) <br />Facility Name. <br />Street Address: City Zip Code, <br />Telephone: County, <br />Submitted By. Date, <br />