Laserfiche WebLink
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: Jerry Johnston <br /> Permittee Company: Jerry Johnston <br /> Address: 13800 Hwy. 24 <br /> Box 99 <br /> Divide, CO 80814 <br /> Phone Number: (719)687-9043 <br /> Fax Number: <br /> Email Address: <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 /> � , . . . ! 4— icy <br /> Signatur: i f Per (1,ee Cor s i f to Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />