2016-03-14_REPORT - M1977251

• Permit No: M1977251
• IBM Index Class Name: Report
• Doc Date: 3/14/2016
• Doc Name: Annual Fee, Report and Map
• From: General Shale Brick, Inc.
• To: DRMS
• Annual Report Year: 2016
• Email Name: MAC
• 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:
I, the undersigned ereby state that the information provided in this report is true and accurate, and that site operations are
being conducted i a cordance with the Division approved mining and reclamation plans.
gnature of Per ittee Cor s orate Officer Owner, or Documented Designee
M -AF -01
ate