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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: David Valdez <br /> Permittee Company: Colorado City Metropolitan <br /> District <br /> Address: 4497 Bent Brothers Blvd. <br /> P.O. Box 20229 <br /> Colorado City,CO 81019 <br /> Phone Number: (719)676-3396 <br /> Fax Number: (719) 676-3172 <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 /> beiinconducted in accordance with the Division approved mining and reclamation plans. <br /> I ) l_ A <br /> qv <br /> Signature of Permittee,Corporate • r Owner,or Documented Designee Date <br />