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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 /> C 1� <br /> Permittee Company: General Shale Brick, Inc. <br /> Address: 1845 W.Dartmouth Ave. <br /> Denver, CO 80110-1308 <br /> Phone Number: (303)783-3041 (3 Q3 782 �� r] <br /> Fax Number: (303)783-2992 J <br /> Email Address: j( l <br /> flCq�'c��t�.:i'�ic.f�{� Na �% ('ihC•rQ���J�l 1C. c.v <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 /> Z� //Xl �4 <br /> Signature of P4rj6flttee.to,a2Krate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />