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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: <br />Ken Coulson <br />Permittee Company: <br />Coulson Excavating Company, <br />Inc. <br />Address: <br />3609 North County Road 13 <br />Loveland, CO 80538 <br />Phone Number: <br />(970) 667-2178 <br />Fax Number: <br />(970) 667-2193 <br />Email Address: <br />Sandy@coulsonecom <br />X <br />SQ- `i, <br />Co u /Son <br />y , <br />o a $ <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 />O/1{ � 'Y 1 r / ( C �c`L_1L 6.P j <br />/ <br />Signature of Permittee, Corporate Off er, Owner, or Documents esi nee <br />M -AF -01 <br />a 9 /Ai <br />Dat <br />