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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 />Dean Ormiston <br />Permittee Company: <br />Baca County <br />Address: <br />741 Main St.,Suite 1 <br />Springfield, CO 81073 <br />Phone Number: <br />(719) 523-6532 <br />Fax Number: <br />(719) 523-6584 <br />Email Address: <br />Dormiston@bacacountyco.gov <br />I, the undersigned, hereby state g the information provided in this report is true and accurate, and that site operations are <br />bei •_�•i • in accordanc IIT he Division approved mining and reclamation plans. <br />Sign . <br />M -AF -04 <br />4, <br />ure : P mittee, <br />ate Officer, Owner, or Documented Designee Date <br />