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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: Justin T.Hersh <br /> Permittee Company: Larimer County <br /> Address: P.O. Box 1190 <br /> Fort Collins,CO 80522 <br /> Phone Number: (970)498-5662 <br /> Fax Number: (970)498-5678 <br /> Email Address: Hershjt@co.larimer.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 •• accordan with the Division approved mining and reclamation plans. <br /> 5 09 0906 <br /> Signat e of Per ttee, or rate Officer,Owner,or Documented Designee ate <br /> M-AF-04 <br />