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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: Dan Hicks <br /> Permittee Company: Rio Grande Ranch,LLC <br /> Address: P.O.Box 880 <br /> South Fork,CO 81154 <br /> Phone Number: (719)849-3421 <br /> Fax Number: <br /> Email Address: Mary@RIRPOA.com Or i P- Pot . C&,(n <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 /> C - a!� ao i� <br /> Signature of Kimittee,Corporate Officer er,or Documented Designee Date <br /> M-AF-01 <br />