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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 />ignature •f Corpor <br />C) 20 1 <br />Date <br />telf) <br />ANNit FEE and REPORT REQUEST <br />c -rGeneral Shale Brick, Inc. dba Robinson Brick Company <br />''M -1984 -076 <br />DDD <br />J <br />RECEIVED <br /><G 01 2011 <br />August 9, 2011 4 Division of Reclamation, <br />$$791.00 (Due on or before your anniversary date) Mining and Safety <br />Elbert <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 -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 />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 />cer, Owner, or Designee <br />n <br />omp <br />