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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 />Dale Kortz <br />Permittee Company: <br />Forest Lakes Metro District <br />Address: <br />P.O. Box 440 <br />Bayfield, CO 81122-0440 <br />Phone Number: <br />(970) 884-2925 <br />Fax Number: <br />(970) 884-0305 <br />Email Address: <br />FLMD@FLMD.com <br />I, the undersigned, h eby 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 />tike_ <br />Signature of PermitteCorporate Officer, Owner, or Documented Designee <br />M -AF -04 <br />1 <br />1 <br />Date <br />