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1 <br /> Page 5 of 5 <br /> Division records indicate the following pennittee contact information, If this information is not current,please type or print <br /> gent contact information: <br /> Permittee Contact: Marcy Brossman <br /> Penmittee Company: Cheyenne County <br /> Address: P.Q.Box 567 <br /> Cheyenne Wells,CO 80810 <br /> Phone Number: (719)767-5872 <br /> Fax Number: (719)767-5753 <br /> Email Address: ccadmin@rebeltec.net <br /> I,the undersigned,hereby state that the information pro-sided 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 /> ; 6 fn "u l- Administrator 1-6-16 <br /> Signature of PeELiittce,Corporate Officer Owner,or Documented Designee Date <br /> hI-AF-W <br />