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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 />John M. Everitt <br />Permittee Company: <br />John M. Everitt <br />Address: <br />24274 CR 17 <br />Haxtun, CO 80731 <br />Phone Number: <br />(970) 774-7508 <br />Fax Number: <br />Email Address:_ <br />3 <br />i C!T <br />J <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 <br />M -AF -01 <br />Owner, or Documented Designee <br />Date <br />