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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 />Tammie Crawford <br />Permittee Company: <br />Park County <br />Address: <br />P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: <br />(719) 836-4283 <br />Fax Number: <br />(719) 836-4275 <br />Email Address: <br />Tcrawford@parkco.us <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 />� ac,,6wE <br />Signature of Permittee, Corporate Officer, Ow <br />M -AF -04 <br />, or Documented Designee <br />