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Page 5 of 5 <br /> Division records indicate the following permittee contact information. If this information is not current,please type or print <br /> current contact information: <br /> Permittee Contact: Tony Fabrizio <br /> F-I �r) <br /> Permittee Company: General Shale Brick, Inc. <br /> Address: 1845 W.Dartmouth Ave. <br /> Denver,CO 80110-1308 <br /> Phone Number: (303) 783-3041 <br /> (30�) 7,2 ` ��� <br /> Fax Number: (303) 783-2992 <br /> Email Address: <br /> 1,the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br /> being conducted in accordance with the Division approved mining and reclamation plans. <br /> Signature of r 'ttee r ate Officer,Owner,or Documented Documented Designee Date <br /> M-AF-01 <br />