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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 />Bennie Koch, Jr. <br />Permittee Company: <br />Rocky Mountain <br />LLC <br />Excavating, <br />Address: <br />2976 L Path <br />Cotopaxi, CO 81223 <br />Phone Number: <br />(719) 942-4311 <br />Fax Number: <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 in accordance with the Division approved mining and reclamation plans. <br />Signature of Permittee, Corporate Officer, Owner or Documented Designee <br />M -AF -04 <br />12-1-1-15 <br />Date <br />