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Page 4 of 4 <br />Division records indicate the following permittee/landowner contact information. If this information is not current, please <br />type or print current contact information: Rule 5.6.1(a, b). <br />Permittee Contact: <br />Jack Clark <br />Permittee Company: <br />Jack Clark, Jr. <br />Address: <br />P. O. Box 767 <br />Silverton, CO 81433 <br />Phone Number: <br />(970) 387 -5243 <br />Fax Number: <br />Email Address: <br />CF.PR.email <br />Landowner Contact: <br />J AG je CI- 9,c R <br />Landowner Address: <br />QwGO�,�f <br />/-7POr 60H- Gv. at3 <br />Landowner Phone <br />Number: <br />9�d -387— "4-3 <br />Landowner Email <br />4C j #.4dP .Ae Adl ECG <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 NOI and reclamation plans. Rule 5.6.1(h). <br />Signature of Permittee oraorate Offi er, Owne r Documented Designee Date <br />