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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: Mike A. Tezak <br /> Permittee Company: Tezak Stone&Aggr Supply Inc <br /> Address: 6200 CR 37 <br /> Texas Creek, CO 81223 <br /> Phone Number: (719)275-1146 <br /> Fax Number: (719)275-1146 <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 /> izAc /11/ / <br /> / <br /> Signature of Permittee, �/rporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />