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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: Evan Melby <br /> Permittee Company: Evan L. Melby, Inc. <br /> "Address: P.O. Box 4159 <br /> Ventura,CA 93007 <br /> Phone Number: (800) 858-8565 <br /> Fax Number: (805) 647-3601 <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 fficer, ner,or Documented Designee Date <br /> M-AF-01 <br /> tggq.o-73 <br /> EGEIVED <br /> MAR 09 Z016 <br /> ►0% <br /> pNi�ION 'SINE IMApMINERALS <br /> 5'V <br />