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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 />Cynthia L. Schmid <br />Permittee Company: <br />Michael G. Erker and Cynthia L. <br />Schmid <br />Address: <br />4803 Prairie Ridge Drive <br />Fort Collins, CO 80526 <br />Phone Number: <br />(720) 363-9108 <br />Fax Number: <br />Email Address: <br />/1 i �� <br />1. Io <br />QrnatJ •c.011--. <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and t at site operations are <br />being conducted in accordance with the Division approved mining and reclamation plans. <br />Signatu (' of Permittee, Corporate Officer, Owner, or Documented Designee <br />M -AF -04 <br />V/5/7—'9/ <br />� <br />Date <br />