2016-01-15_REPORT - M1977252

• Permit No: M1977252
• IBM Index Class Name: Report
• Doc Date: 1/15/2016
• Doc Name: Annual Fee, Report and Map
• From: General Shale Brick, Inc.
• To: DRMS
• Annual Report Year: 2016
• Email Name: TOD
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee contact information. If this information is not current, please type or print
current contact information:
Permittee Contact:
Tony Fabrizio
Permittee Company:
General Shale Brick, Inc.
Address:
1845 W. Dartmouth Ave.
Denver, CO 80110-1308
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.
14(4/1,6
Si ature ' f Pe mittee, Corporate Officer, Owner, or Documented Designee Date
M -AF -01