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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: Ricky W.Mitchell <br /> Permittee Company: Ricky W. Mitchell <br /> Address: P.O. Box 10 <br /> Bennett,CO 80102 <br /> Phone Number: (303) 644-4102 <br /> Fax Number: <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 /> — /'4�1 V" � "'V- -Zlallz <br /> Signature of Per ittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />