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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: Martin Azcarraga <br /> Permittee Company: M.A.Concrete Construction, <br /> Inc. <br /> Address: 2323 River Road <br /> Grand Junction,CO 81505 <br /> Phone Number: (970)243-3221 <br /> Fax Number: (970)243-9757 <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 /> AXA -3v-1 <br /> Signature of Permi ee C r orate Officer, Owner, or Documented Designee Date <br /> M-AF-OI <br />