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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: Doug Derr !/ <br /> Permittee Company: Broken Arrow Investments LLC <br /> Address: 801 8th St., Ste. 130 <br /> �QI <br /> Greeley, CO 80631-3903 <br /> Phone Number: (970)454-8816 '7 a. 6 Gr _ 50g. <br /> Fax Number: <br /> Email Address: <br /> /17/G%4t26-. W<-�f,�i2 V. <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 wi the Division approved mining and reclamation plans. <br /> Sign• ure of P• •• •e o ate II fficer,Owner,or Documented Designee Date <br /> M-AF-01 <br />