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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: Travis R.Crawford <br /> Permittee Company: Silver Mountain Preserve,Inc. / <br /> Address: 11850 CR 520 <br /> La Veta,CO 81055 <br /> Phone Number: (719)742-3971 <br /> Fax Number: (719) 868-2416 <br /> Email Address: <br /> 1,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are <br /> being conducted in rdance with the Division approved mining and reclamation plans. <br /> Signature of Permittee, Corporate Officer, caner,or Documented Designee Date <br /> M-AF-01 <br />