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Page 5 o£# <br />-p;o„isiuon words <br />indicate the following p caatact infortnotton. 1f this imfounst on ie not ; Please tYPe or pant <br />nt contact infon nation <br />Permittee Contact! jack Clark Jr <br />ermittee Conry: lack Clark,, Jr. <br />Address: P. O. Box 767 <br />Werke, CO g1433 <br />Phone Number: (970) 387-5243 <br />PaxNumber: (970) 387-5121 <br />Eassankddrciast <br />Cirri r <br />the undersigned, state that the inform 'pr'ovided m this report is accurate, and that site operations are <br />� informatics <br />being odd ioa accaraaace with t'Divisi ou : a Q ror,larastion pimps, <br />Date <br />