2017-08-09_REPORT - M1979221

• Permit No: M1979221
• IBM Index Class Name: REPORT
• Doc Date: 8/9/2017
• 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: Harold Stickler
Permittee Company: General Shale Brick, Inc.
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone]
Fax Number: [phone]
Email Address: [e-mail]
Permitting Contact: Tony Fabrizio
Company: General Shale Brick, Inc.
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone] I S--/(:73'
3_ 3 n53
Fax Number: [phone] (3 03i r-T83 -a 9 9
l
Email Address:
jO\ C)0 v 6), re.v111 iNgle,Coo
Inspection Contact: Tony Fabrizio
Company: General Shale Brick, Inc.
Address: 1845 W. Dartmouth Ave.
Denver, CO 80110-1308
Phone Number: [phone] ( 3 092) 7-a7) 30
Fax Number: [phone]
(30 \7S-3-319
Email Address: n c�
I,the undersigned,hereby state that the information provided in this report is true and a*c'curate, and Nat site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
47
Signature s P•rmitte I orate Offic• ,Owner,or Documented Designee Date
M-AF-0 1