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Page 5 of 5 <br /> Division records indicate the following permittee contact information. If this information s not current,please type or print <br /> current contact information: <br /> Permittee Contact: Timothy D.Williams <br /> Permittee Company: Timothy D.Williams&Betty J. <br /> Williams <br /> Address: 5588 CR 210 <br /> Walsenburg,CO 81089 <br /> Phone Number: (719)738-6263 <br /> I <br /> Fax Number: <br /> Email Address: <br /> I,the undersigned,hereby state that the information provided in this report is true and acc rate,and that site operations are <br /> being conducted in accordance with the Division approved mining and reclamation plans. <br /> �1� — <br /> Signature oftermittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />