2021-08-23_REVISION - M1976007UG

• Permit No: M1976007UG
• IBM Index Class Name: Revision
• Doc Date: 8/23/2021
• Doc Name: Completeness Response
• From: Denver Brick Co.
• To: DRMS
• Type & Sequence: CN1
• Email Name: ECS
• Media Type: D
• Archive: No

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(if an entity) _
(Caution: Do not provide both an individual and an entity name.)
Street address
(Street number and name) ;
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(City) (Satre) (Z1P Code)
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aili address `
(leave blank,if same as street address) (Strut number and name or Post Office Box information)
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(City) (State) (7JP Code)
6, (ljapplicable,adopt the following statement by marldng the box and include an attachment)
This document contains additional information as provided by law.
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7.(Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has significant
legal consequences. Read instructions before entering a date)
(If the following statement applies,adopt the statement by entering a date and.(f applicable.time using the required format)
The delayed effective date and,if applicable,time of this document are i
(mm/ddlyy)y hour--minute onvtom) 1
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery,under penalties of perjury,that such document is
such individual's act and deed,or that such individual in good faith believes such document is the act and deed
of the person on whose behalf such individual is causing such document to be delivered for filing,taken in
conformity with the requirements of part 3 of article 90 of title 7,C.R.S.and,if applicable,the constituent
documents and the organic statutes,and that such individual in good faith believes the facts stated in such
document are true and such document complies with the requirements of that Part,the constituent documents,
and the organic statutes. '•.
This perjury notice applies to each individual who causes this document to be delivered to the Secretary of
State,whether or not such individual is identified in this document as one who has caused it to be delivered.
8. The true name and mailing address of the individual causing this document to be delivered for filing are
Green Richard L.
(Lwt) (First) (Middle) (Sifftx)
c/o General Shale Brick,Inc.
(Street number and name or Post Office Box information)
3211 N.Roan Street
Johnson City TN 37601
(City) (Stale) (L/P/Pasral Code)
USA
(Province—ijapplicable) (Country)
(If applicable,adopt the following statement by marking the box and include an attachment)
�] This document contains the true name and.mailing address of one or additional individuals 1.
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causing the document to be delivered for filing.
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MERGE P! Page 4 of 5 Rev.5/29/2007 :1