2017-01-13_REPORT - M1977252

• Permit No: M1977252
• IBM Index Class Name: Report
• Doc Date: 1/13/2017
• Doc Name: Annual Fee/Report/Map
• From: General Shale Brick, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: PSH
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact information (blank fields indicate that we do not have
information on record). If this information is blank or not current, please type or print current contact information:
Permittee Contact:
Tony Fabrizio
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Permittee Company:
General Shale Brick, Inc.
Address:
1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number:
[phone]
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Fax Number:
[phone]
Email Address:
[e-mail]
Permitting Contact:
Company:
General Shale Brick, Inc.
Address:
1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number:
-
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Fax Number:
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Email Address:
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Inspection Contact:
Te�e
Company:
General Shale Brick, Inc.
Address:
1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number:
-
303 7/93 -305�g
Fax Number:
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Email Address:
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I, the undersigned, hereby state that the information provided in this report is true and accura , and that site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
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Signature of Per ttee, Co a Officer, Owner. or Documented Designee Date
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