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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 />Randy Schafer <br />Permittee Company: <br />Phillips County <br />Address: <br />221 S. Interocean Ave. <br />Holyoke, CO 80734 <br />Phone Number: <br />(970) 854-3778 <br />Fax Number: <br />(970) 854-3811 <br />Email Address: <br />141lady, scAy4,--610 /d,4 <br />440d <br />.eO <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 />44iSignature of P Coporate Officer, Owner, or Documented Designee Date <br />//%6—//3 - <br />M -AF -04 <br />