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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 />PeterL. Dawson <br />Permittee Company: <br />Baca County <br />Address: <br />741 Main St.,Suite 1 <br />Springfield, C081073 <br />Phone Number: <br />(719) 523-6532 <br />Fax Number: <br />(719) 523-6584 <br />Email Address: <br />Pdawson@bacacountyco.gov <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�accordancy,,vyith the Division approved mining and reclamation plans. <br />Signature ofPermittee, Corporate Officer, Owner, or Documented Designee <br />M -AF -04 <br />% / 11r <br />- <br />Date <br />1rDate <br />