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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Tony Fabrizio <br />Address: 1845 W. Dartmouth Ave. <br />Phone Number: <br />Fax Number: <br />Denver, CO 80110 -1308 <br />(303) 783 -3041 <br />(303) 783 -2992 <br />facer, Owner, or Designee <br />"7 <br />ANNUAL FEE and RE OR REQUEST <br />Brick Company <br />A eneral Shale Brick, Inc. dba Robinson <br />- 1978 -014 <br />North Chieftain <br />August 14, 2011 <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 map is required, provided that the Operator shall state <br />this 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 Name: General Shale Brick, Inc. <br />I <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 />R ECEIVED <br />AUG 012011 <br />/„Division of keaamation, <br />I v Mining and Safety <br />