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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 print <br /> current contact information: <br /> Permittee Contact: Randy Burks <br /> Permittee Company: Western States Minerals,LLC <br /> Address: 7964 E. Homestead Rd. <br /> Parker,CO 80138 <br /> Phone Number: (303) 919-9668 <br /> Fax Number: <br /> Email Address: <br /> 1,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are <br /> being co ucted in accordance with the Division approved mining and reclamation plans. <br /> ✓�� 2 <br /> gn ture of Permittee, Corporate Officer,Owner,or Documented Designee 4te <br /> M-AF-02 <br />