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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 />MarcyBrossman <br />Permittee Company: <br />Cheyenne County <br />Address: <br />Phone Number: <br />P.O. Box 567 <br />Cheyenne Wells, C080810 <br />(719) 767-5872 <br />Fax Number: <br />(719) 767-5753 <br />I <br />Email Address: <br />Ccadnnin@rebeltec.net <br />I, the undersigned, hereby state that the information provided in this repot 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 -AM <br />County Administrator <br />Owner, or Documented Designee <br />8/19/2015 <br />Date <br />