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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: 1--A E-er1 <br />Permittee Company: Montezuma County <br />Address: 1680 North Dolores Road <br />Cortez, CO 81321 <br />Phone Number: 970) 565-8666 <br />Fax Number: 970) 565-8252 <br />Email Address: <br />V O (LL' ' C!L . do Lvs <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, Nrporate Ofbicer, Owner, or Documented Designee <br />M -AF -04 <br />1 <br />Date