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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: Joe H.Thomeczek <br /> Permittee Company: Bent County Ready Mix <br /> Address: P.O.Box 387 <br /> Las Animas,CO 81054 <br /> Phone Number: (719)456-1320 <br /> Fax Number: <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 /> / 4 - / - g <br /> Signat ,of Permittee, Corpora 4Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />