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Page 5 of 5 <br /> <br />Division records indicate the following permittee contact information. If this information is not current, please type or print <br />current contact information: <br /> <br />Permittee Contact: <br /> <br />Dave Johnston <br />Permittee Company: <br /> <br />City of Walsenburg <br />Address: <br /> <br /> <br /> <br />525 S Albert <br /> <br />Walsenburg, CO 81089 <br /> <br />Phone Number: <br /> <br />(719) 738-1048 <br />Fax Number: (719) 738-1875 <br />Email Address: Djohnston@cityofwalsenburg.com <br /> <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 /> <br /> <br /> <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date <br /> <br />M-AF-04 <br /> <br />