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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: Mason Chamberlain <br /> Permittee Company: Chamberlain Concrete <br /> Address: 36415 U. S. Highway 385 <br /> P O Box 425 <br /> Wray, CO 80758 <br /> Phone Number: (970)332-4355 <br /> Fax Number: (970)332-4081 <br /> Email Address: Masonchamberlain@yahoo.com <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 /> ` 16 -16 <br /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />