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Page 5 of 5 s <br />Division records indicate the following permittee contact information. If this information is not current, please type or <br />print current contact information: <br />t. <br />Permittee Contact: <br />Cliff Hoelscher <br />i <br />Permittee Company: <br />City of Fort Collins <br />Address: <br />700 Wood Street <br />P O Box 580 <br />Fort Collins, CO 80522 <br />Phone Number: <br />CF.PR.telephone_number <br />Fax Number: <br />Email Address: <br />Choelscher@fcgov.com <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 />of Permittee. Corporate Officer, Owner, or Documented Designee <br />M -AF -OI <br />� -4- I b <br />Date <br />