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OMB# <br /> EViration Date: <br /> AML CONTRACTOR INFORMATION FORM <br /> Completion of the following information is necessary to obtain an AVS data evaluation to <br /> determine your eligibility as a contractor. This is a requirement under 30 CFR 874.16. <br /> Part A: General Information <br /> Contractor Name: BITTERROOT RESTORATION, INC. Tax Payer ID No.: 81-0440317 <br /> Address: 445 Quast Lane <br /> City: Corvallis State: MT Zip Code: 5 828 Phone: 406 961-4991 <br /> Part B: Legal Structure <br /> (x ) Corporation ( ) Sole Proprietorship ( ) Partnership ( ) LLC <br /> ( ) Other <br /> Part C: Ownership/Control Information: <br /> Select the statement that best describes your situation and follow the instructions. <br /> The ownership/control information currently listed in AVS is accurate and complete. <br /> (Skip to Part"D - Certification" and select appropriate statement.) <br /> The ownership/control information currently listed in AVS must be updated or modified <br /> to reflect recent changes. (Indicate below the information that should be added to the <br /> AVS, then go to Part"D - Certification" and select appropriate statement.) <br /> x The ownership/control information for this entity is NOT listed in the AVS. (Indicate <br /> below the information that should be added to the AVS, then go to Part"D - <br /> Certification" and select appropriate statement.) <br /> You must provide information below for the following relationships: officers/directors, <br /> persons/companies owning greater than 10%of voting stock; partners; members; person(s)who <br /> commit the financial, real estate or working assets; and person(s)who have the authority to <br /> determine the manner in which you conduct the AML reclamation project. <br /> Name Patrick M. Burke Position/Title President <br /> Address 445 Quast Lane Telephone# 406 961-4991 <br /> Corvallis, Montana 59828 <br /> Name Maurice W. Burke Position/Title Board Member <br /> Address Post Office Box 432 Telephone# 925 838-9070 <br /> Alamo, California 94507 <br /> Name Mary Ann Burke Position/Title Stockholder <br /> Address 171 Via Bonita Telephone# <br /> Alamo, California 94507 <br /> (If additional space is required please attach separate sheet) <br /> 1 <br />