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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: Justin T.Hersh <br /> Permittee Company: Larimer County <br /> Address: P.O.Box 1190 <br /> Fort Collins,CO 80522 <br /> Phone Number: (970)498-5662 <br /> Fax Number: (970)498-5678 <br /> Email Address: Hershjt@larimer.org <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 i accordan e with th Division approved mining and reclamation plans. <br /> 1 )0 ),46 l CP <br /> Signatur of Perm' t e Co rate Officer Owner,or Documented Designee ate <br /> M-AF-04 <br />