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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: Dean Goss <br /> Permittee Company: David Goss <br /> Address: 24040 Falcon Hwy <br /> Calhan, CO 80808-9156 <br /> Phone Number: (719) 683-4295 <br /> Fax Number: (719) 683-2645 <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, orporate Officer,Owner,or Documented Designee bkite <br /> M-AF-01 <br />