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Page 5 of 5 <br />Division records indicate the following pennittee contact information. If this information is not current, please type or print <br />current contact inforniation: <br />Permittee Contact: MarcyBrossman <br />Permittee Company: Cheyeime County <br />Address: P.O. Box 567 <br />Cheyenne Wells, CO 80810 <br />Phone Number: 719) 767-5872 <br />Fax Number: 719) 767-5753 <br />Email Address: Ccadmin@rebeltec.net <br />I, the undersigned, hereby state that the information provided in this report is tike and accurate, and that site operations are <br />being conducted in accordance with the Division approved mining and reclamation plans. <br />Administrator 10-8-15 <br />of Pq iittee, Corporate Offices:, Owner, or Documented Designee Date <br />M.AM