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_ . _ <br />05/08i2003 14:39 FAX 541 683 57fl8 ELTGENE SAND & GRAVEL -~ Eubene Pub Works [~J001 <br />. ~ ~ I ~ <br />4 ' V ~ <br />~ ~ I <br />~ ~ <br />'~ 6 1f dving business under an assumed businErss name, fiil out the foliowing informationt (Requireci) ~ EVA <br />Assumed business nam~: <br />Owne~s narne and address: <br />Oregon Secsetary of SF~te Corporatian Dir%~sion's REgis:trafion Number: Renewa{ <br />ltennnn~ffinninnronnn rnm/hi~rr+nPnriax.h4m1 . ' DetE: <br />~ OWNERSHiP AIVD CON3ROL (A~, S, and C are al) Re~uired) <br />(a) 15 there any otg~r+ization, owned or controllecl by the applican~ its of~cers, director5, pa~ners and anyone <br />owning at least 'E 0 percent interest in ~e firm., or ir1 whieh th~ appiicant was or is an ofFcef, director, <br />partner, doing business in ~regon under ano~;her name? <br />~ Yes ^ No If yes, please list 9n space below. lf no, write N/A in space below. <br />Green & W3ute Rock P=odacts <br />V~.dng 3~tedi.-Mix <br />Bav,dou Rcdi-Mix <br />(b) Are there any individuak5, campanies or co~'porations owning 10 percent or rnore of applicant's firm? <br />~ Yes ^ No lf yes, piease list in space below. If no. wfite N/A in ~pace below. <br />CoYporation <br />(c) Are there any other ps~sonne! in appiicanf`s carganization who have a'~~nancial in#erest in or serve as <br />ofFcers or p~r~ner5 in another fmi prequafifiE:d ta bid in this or another state? <br />[~ Yes ^ No {f yes, pleasE: list below irt space pt'ovicied_ lf no, wri'te NA in'space below. <br /> <br />Indiv9dual's Name PreSent Position or <br />Other Firm 4r Firrrrs Pmsition in Other State vf Otiher <br /> <br />O~f ce ~irm s Firm <br />P~ul Sa3.~sb~ y CFO GPM D~ve]~opmerit CFO WA, OR <br />KC:'.:Klost~rma VP CPM b~velopntent VP WA, OR <br />M~ke Dyer <br />I Asst Sec CPM Deve~.opmen~ I~isst Sec WA, OR <br />S DtSADVANTAG~d 6USIi~~SS ENT~RPRISE <br />Js your firm currently certified by the State of Oregon as a Qisadvant~ged Busines5 ~nterprise (DB'E)? (RBqu~red) <br />(Check ane) ^ Yes ~ No <br />zDD7-06 Pfime Goniraclor ~reqaeGfmqon AppliCet~on ~ PBQe ° ~ Rev~sey January 20a7 <br />05/08/2008 THU 14:4~ (T~lFX t~0 96501 Cd.1001 <br />