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r <br />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 />Dean Ormiston <br />Permittee Company: <br />Baca County <br />Address: <br />741 Main Street, Suite 1 <br />Springfield, CO81073 <br />Phone Number: <br />(719) 523-6532 <br />Fax Number: <br />1 l tel. 52,3•CPS�� <br />Email Address: <br />Dormiston@bacacountyco.giv <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />being c coed in accordance with tjz6 Division approved mining and reclamation plans. <br />or Documented Designee Date r <br />M -AF -04 <br />