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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: Rick Domson <br /> Permittee Company: Breeze Basin Resources <br /> Address: PO Box 181 <br /> Hayden,CO 81639 <br /> Phone Number: (970)326-8689 <br /> Fax Number: (970)824-2840 <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 Date <br /> M-AF-01 <br />