2017-03-06_REPORT - M1990143

• Permit No: M1990143
• IBM Index Class Name: REPORT
• Doc Date: 3/6/2017
• Doc Name: Annual Fee/Report/Map
• From: General Shale Brick, Inc.
• To: DRMS
• Annual Report Year: 2017
• Email Name: ERR
• 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: Anthony Fabrizio
Permittee Company: General Shale Brick, Inc.
Address: 1845 W. Dartmouth Ave.
Denver,CO 80110-1308
Phone Number: [phone] -33
Fax Number: P 17
Email Address: J
Permitting Contact: Anthony Fabrizio
Company: General Shale Brick, Inc.
Address: 1845 West Dartmouth Avenue
Denver,CO 80110
Phone Number: [phone]
Fax Number:
Email Address: vQ J0_ . P�,r.r t �t , !t� �r r., r{ I �, F r{�� . .,�f's 1
Inspection Contact: Anthony Fabrizio r
Company: General Shale Brick, Inc.
Address: 1845 West Dartmouth Avenue
Denver,CO 80110
Phone Number: [phone]
Fax Number:
Email Address:
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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.
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Signature/of Permittee,J26rporate Officer,Owner,or Documented Designee Date
M-AF-01