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Page 5 of 5 <br />Division records indicate the following permittee contact information. If this information is not current; please type or <br />print current contact information: <br />Permittee Contact: Richard F. Wyatt <br />Permittee Company: Wyatt Redi-Mix Company <br />Address: 690 Harrison Street <br />P.O. Box 1052 <br />Walden, CO 80480 <br />Phone Number: 970) 723-4471 <br />Fax Number: 970) 723-3222 <br />Email Address: <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />being conducted in accordance with the Division approved mining and reclamation plans. <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee <br />M -AF -01 <br />Date