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ni <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 />MarioBassi <br />Permittee Company: <br />Mario Bassi and Josephine Bassi <br />Address: <br />2000 N. Farm Rd. <br />Monte Vista, CO81144 <br />Phone Number: <br />(719) 852-3225 <br />Fax Number: <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 />M -AF -01 <br />9 -19 - <br />Date <br />