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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: Joseph L.Dorris <br /> Permittee Company: Glacier Peak Art,Gems&Minerals <br /> Address: 2920 Cedar Heights Dr. <br /> Colorado Springs,CO 80904 <br /> Phone Number: (719)685-4479 <br /> Fax Number: <br /> Email Address: Glacierpeak@pinnacle5minerals.com <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 /> %.2(4t-e--1)7 `kW-4 ' /6 <br /> Signatur oer iftee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-02 <br />