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Page 5 of 5 <br />livision records indicate the following permittee contact information. If this information is not current, please type or print <br />c rrent contact information: <br />'ermittee Contact: <br />Mark Dorenkemp <br />ermittee Company: <br />Prowers County <br />Address: <br />109 E. Sherman St. <br />Lamar, CO 81052 <br />Phone Number: <br />(719) 336-5536 <br />Fax Number: <br />(719) 336-9633 <br />)'mail 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 ccordan with the Division a pro ed mining and reclamation plans. <br />rr t•sx " nA0�/ <br />Signature of Permittee, Corpov(te Officer, Owner, or Documented Designee Date <br />M -AF -04 <br />