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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: Randy Burks <br /> Permittee Company: Western States Minerals,LLC <br /> Address: 7964 E. Homestead Rd. <br /> Parker,CO 80138 <br /> Phone Number: (303)919-9668 <br /> Fax Number: <br /> Email Address: Grubstacker@aol.com <br /> I,the and i ed,hereby state that the information provided in this report is true and accurate, and that site operations are <br /> being c d cted in ac a ce it on approv mining and reclamation plans. <br /> ig ature of Permittee,Corporate Officer,Owner,or Documented Designee Dke <br /> M-AF-02 <br />