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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: <br />Thomas G. Mathias <br />Permittee Company: <br />Mathias Concrete, Inc. <br />Address: <br />1500 N. Farm Rd. <br />P.O. Box 266 <br />Monte Vista, CO 81144 <br />Phone Number: <br />(719) 852-3732 <br />Fax Number: <br />(719) 852-3759 <br />Email Address: <br />Mathias_concrete@yahoo.com <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 Offi r, Owner, or Documented Designee Date <br />/- ,E--- ., a 4 <br />M -AF -01 <br />