2017-03-06_REPORT - M1977251

• Permit No: M1977251
• 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: MAC
• 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
Permittee Company: General Shale Brick, Inc.
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone] �03 C7, 3
Fax Number: [phone]
Email Address:
Permitting Contact: Tony Fabrizio
Company: General Shale Brick, Inc.vHga
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone] C3 � r�S3. SOD
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Fax Number: [phone] t
Email Address: ll
Inspection Contact: Tony Fabrizio
Company: General Shale Brick, Inc.-dba-
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone]
Fax Number: [phone]
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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Signat re of Permilkt<Corporate Officer,Owner,or Documented Desienee Date
M-AF-01