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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 />SamKeeling <br />Permittee Company: <br />Sam Keeling <br />Address: <br />P0Box 361 <br />LaVeta, COS 1055 <br />Phone Number: <br />(719) 742-5557 <br />Fax Number: <br />Email Address: <br />Samlaveta@earthlink.net <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 />#--- 141:11, 'Z" 1-;;k- Lir- <br />Signature ofPermittee Cor, orat facer, Owner, or Documented Designee Date <br />M -AF -01 <br />