2013-07-05_REPORT - M1989120

• Permit No: M1989120
• IBM Index Class Name: REPORT
• Doc Date: 7/5/2013
• Doc Name: ANNUAL FEE/REPORT
• From: OPERATOR
• To: DRMS
• Email Name: PSH
• Media Type: D
• Archive: No

Colorado Department of Public Health & Environment
Recycling Facility Annual Reporting Form
Reporting form must be submitted by March 1, 2013
Name of facility: Broda's Inert Fill - Al Platte Valley Pit
Address: 1859 Hwy 85
City: Brighton
ZIP code: 80603
Mailing Address: Same
# of Recycling Employees: 4
Contact person: Patrick Broda
Phone: [phone]
E -mail: molenassociates(a�gmail.com
Reporting Period: Calendar Year 2012
Instructions
Save a copy of this file to your computer. Enter data and email the completed form to:
cdphe.hmrecyclina @state.co.us or print and mail to: Wolf Kray
CDPHE HMWMD -SW -B2
4300 Cherry Creek Dr. South
Denver, CO 80246
Any records in our possession identified as "confidential business information" or as a "trade secret"
will not be disclosed without giving the party raising the claim notice of the request and an
opportunity to contest the release of the information. The burden of proving that the information is
protected as a trade secret is on the party raising the claim. In order to claim this protection, you
must meet the following requirements:
1. you must show that you have taken reasonable measures to protect the confidentiality of the
information, and that you intend to continue to take such measures;
2. the information is not, and has not been, reasonably obtainable without your consent by other
persons using legitimate means;
3. either:
i. you have satisfactorily shown that disclosure of the information is likely to cause substantial harm
to your competitive position; or
ii. the information is voluntarily submitted information and its disclosure would be likely to impair
the Government's ability to obtain necessary information in the future;
4. no statute specifically requires disclosure of the information; and
5. you have to assert a claim of business confidentiality in writing. You may do so by checking the box
below, adding your facility information and submitting along with your reporting forms.
I have read Items 1 -5 and am hereby requesting that information submitted on my Recycling Facility
ReInrting Forms be kept as confidential information.
Yes. (Box MUST be checked to claim privilege)
Facility Name:
Street Address: City: Zip Code:
Telephone: County:
Submitted By: Date:
Submit only one confidentiality form per facility. Applies only to facility identified above.