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X62 <br />?P- <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />v <br />AN AL FEE and <br />PORT REQUEST <br />` <br />neral Shale Brick, Inc. <br />v M-1978-014 <br />North Chieftain <br />014, <br />AUG 0 3 2010 <br />Division (if Rzc;Q0VAan, <br />to MinirV and 5601 <br />August 14, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Jefferson <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year,-the dates-for-the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new may is required, provided that the Operator shall state <br />this in the Annual in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Tony Fabrizio <br />Permittee Name: General Shale Brick, Inc. <br />Address: 1845 W. Dartmouth Ave. <br />Denver, CO 80110-1308 <br />Phone Number: (303) 783-3046 / 30 <br />Fax Number: (303) 781-1818 X30 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Officer, Owner, or Designee <br />3?.