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Page 5 of 5 <br /> Division records indicate the following pennittee contact information. If this information is not current,please type or print <br /> current contact information: <br /> Permittee Contact: Fabyan Watrous <br /> Permittee Company: Jack Pine Mining Company <br /> Address: P.O. Box 66 <br /> Idaho Springs,CO 80452-0066 <br /> Phone Number: (303)567-2350 <br /> Fax Number: <br /> Email Address: Jpinemine@aol.com <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 /> '—I- �) a77,7',—.L� 6�1� , — ;:z — <br /> Signature of Vermi ee,Corporate Officer,Owner,or Documented Designee Date <br /> M•AF-02 <br />