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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 />16— <br />1 —Permittee <br />PermitteeCompany: <br />Custer County <br />Address: <br />P.O. Box 1669 <br />Westcliffe, CO 81252 <br />Phone Number: <br />(719) 783-2281 <br />Fax Number: <br />(719) 783-0391 <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 accordance with the Division approved mining and reclamation plans. <br />[� C"-Yto�- 7-zl-is <br />Signature of <br />M -AF -04 <br />O,vN°ner, or Documented Designee <br />Date <br />