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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: Mike Horner <br /> Permittee Company: San Miguel County <br /> Address: P.O.Box 426 <br /> Norwood,CO 81423 <br /> Phone Number: (970)327-4835 <br /> Fax Number: (970)327-4090 <br /> Email Address: <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, Corporate Officer,Owner, or Documented Designee date <br /> M-AF-04 <br />