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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 />Mason King <br />Permittee Company: <br />Mason King <br />Address: <br />P.O. Box 68 <br />Cope, CO 80812 <br />Phone Number: <br />(970) 357-4245 <br />Fax Number: <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 accordar^ce w 4he Division approved mining and reclamation plans. <br />Signature <br />M -AF -04 <br />Owner, or Documented Designee Date <br />