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t <br />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 />Ed BCAS m, <br />4f'it25 &,i&/ <br />Permittee Company: <br />Benson Brothers <br />Address: <br />21240 Austin Rd <br />Austin, CO 81410 <br />Phone Number: <br />(970) 835-3128 <br />Fax Number: <br />(970) 835-8567 <br />Email Address: <br />1?%S/Ji< <br />2mjir1C Y4P <br />/ <br />Le�.D/i-Ai `/ ci XSiocz I. C d /Y� <br />lt <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 />Sign , ure o ' ermittee, Corporate <br />M -AF -01 <br />fficer, Owner, or Documented Designee <br />jo 15 <br />Date <br />