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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 print <br />current contact information: <br />Permittee Contact: <br />Andrew and Rebecca M Kagan <br />Permittee Company: <br />Kagan & Son, L.L.C. <br />Address: <br />555 Ernest Avenue <br />Westcliffe, CO 81252 <br />Phone Number: <br />(719) 783-9636 <br />Fax Number: <br />Email Address: <br />Akagan@centurytel.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 />Signature of Permittee r orate Officer, Owner, or Documented Designee Date <br />M -AF -01 <br />