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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: <br />Anthony Adza <br />Permittee Company: <br />EWSD I, LLC <br />C <br />Address: <br />600 Wilshire Blvd, Suite 1500 <br />/ 3 3 Lim— ; `ILS -V-1 r .4 <br />Los Angeles, CA 90017 <br />Phone Number: <br />(949) 236-9206 <br />Fax Number: <br />Email Address: <br />Aadza@medbox.com <br />Ido A- cc, <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />being condu ed accords cc w' h the Division approved mining and reclamation plans. <br />�0 1 <br />Signature of Permi ee Car rate Officer, Owner. or Documented Designee Date <br />M AF -01 <br />i <br />