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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 />Thomas O'Rourke <br />Permittee Company: <br />O'Rourke Excavating, Inc. <br />Address: <br />2489 CR 15 <br />South Fork, CO 81154 <br />Phone Number: <br />(719) 580-9602 <br />Fax Number: <br />Email Address: <br />Orourkeexcavating@hotmail.com <br />New ia) (t Dd4p-e s y <br />r;( CX I <br />Sag* t oe(c. 6 <br />.3V CY <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 />3-/6-/6' <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date <br />M -AF -01 <br />