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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 <br />print current contact information: <br />Permittee Contact: <br />Phil Esquibel <br />Permittee Company: <br />Conejos County <br />Address: <br />P.O. Box 157 <br />6683 County Rd 13 <br />Conejos, CO 81129 <br />Phone Number: <br />(719) 376-5772 <br />Fax Number: <br />(719) 376-5661 <br />Email Address: <br />Phil@co.conejos.co.us <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 />Signature of Permittee, Corporate Officer, Owner, or Documented Designee <br />M -AF -04 <br />7 7 Lit; <br />ate <br />