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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: Florence Jackson <br /> Permittee Company: Canyon Rim Stone, LLC <br /> Address: 27500 CR 183 <br /> Kim, CO 81049 <br /> Phone Number: (719) 643-5435 <br /> Fax Number: (719) 643-5435 <br /> Email Address: Florrie@ghvalley.net <br /> 1,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 nee,or Documented Desig Date <br /> r <br /> M-AF-01 <br />