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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: Rob Englehart <br /> Permittee Company: Montezuma County <br /> Address: 109 West Main Street <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: <br /> Email Address: Renglehart@co.montezuma.co.us <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 /> Signature of Permittee, Cor rate Officer,Owner,or Documented Designee Date <br /> M-AF-04 '-1 <br />