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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: Laurie Jacobson <br /> Permittee Company: B &L Cogan, L.L.C. <br /> Address: 24800 US. Hwy 285 S. <br /> Buena Vista, CO 81211 <br /> Phone Number: (719) 395-2405 <br /> Fax Number: <br /> Email Address: Jjluko@yahoo.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 c nducted in accordance with the Division approved mining and reclamation plans. <br /> /7 _/6 <br /> Signature of Perm' ee orporate Officer, or Documented Designee Date <br /> M-AF-0 1 <br />