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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 />Michael S. Davis <br />Permittee Company: <br />Dolores County <br />Address: <br />P.O. Box 608 <br />Dove Creek, CO 81324 <br />Phone Number: <br />(970) 677-2328 <br />Fax Number: <br />(970) 677-3759 <br />Email Address: <br />Dcroad@centurytel.net <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 accor ance with the Division approved mining and reclamation plans. <br />- S -aol S <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date <br />M -AF -04 <br />'.. }S , • V <br />