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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 />Michael Iguchi <br />Permittee Company: <br />Keyah Grande Lodge and Elk <br />Ranch <br />Address: <br />13211 Highway 160 West <br />Pagosa Springs, CO 81147 <br />Phone Number: <br />(970) 731-2158 <br />Fax Number: <br />(970) 731-5446 <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 in4c 4iance ith the sion approved mining and reclamation plans. <br />Signature of Permittee, I' porate Officer, Owner or Documented Designee <br />M -AF -01 <br />//-ao•/S <br />Date <br />