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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 />Forrest Neuerburg or <br />Permittee Company: <br />City of Monte Vista <br />Address: <br />95 W, 1st <br />Monte Vista, CO 81144 <br />Phone Number: <br />(719) 852-2692 <br />Fax Number: <br />(719) 852-6161 <br />Email Address: <br />Robertv@co.monte-vista.co.us <br />I, the undersigned, hereby state that the information providedfin this report is true and accurate, and that site operations are <br />being conducted in accordance with the Division approved mining and reclamatiorrplans. r <br />Signature of Permittee Cor orae Officer Owner or Documented Designee <br />M -AF -04 <br />8 y w <br />'4 " y <br />R <br />} <br />! r <br />8 y w <br />'4 " y <br />