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Page 5 of 5 <br /> Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have <br /> information on record). If this information is blank or not current,please type or print current contact information: <br /> Permittee Contact: Mark Balderson <br /> Permittee Company: Rock-N-Pine LLC <br /> Address: 503 Wise St. <br /> Hamlet,NE 69040 <br /> Phone Number: (719)839-0946 <br /> Fax Number: <br /> Email Address: <br /> b r# <br /> Permitting Contact: Mark Balderson <br /> Company: Rock-N-Pine LLC <br /> Address: C/o Tom Giskobsky J'Yfari trs on <br /> P. O. Box 5526 5-03 W�5e_ 64- <br /> Breckenridge,CO 80424 <br /> 1�i��+(tf NE Ca9oyD <br /> Phone Number: (719)839-0946 <br /> Fax Number: (719)839-0946 <br /> Email Address: <br /> Inspection Contact: Mark Balderson <br /> Company: Rock-N-Pine,LLC <br /> Address: C/o Tom Giskobsky <br /> P. O. Box 5526 <br /> Breckenridge, CO 80424 <br /> Phone Number: (719)839-0946 <br /> Fax Number: (719)839-0946 <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 /> Sig ature of Permi tee,Corporate Officer,Owner,or Documented Desisnee Date <br /> M-AF-01 <br />