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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: Marcy Brossman <br /> Permittee Company: Cheyenne County <br /> Address: P.O.Box 567 <br /> Cheyenne Wells,CO 80810 <br /> Phone Number: (719) 767-5872 <br /> Fax Number: (719)767-5753 <br /> Email Address: Ccadmin@rebeltec.net <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 /> fn,ate &N County Administrator 4/18/16 <br /> Sig natui e of Pttee,Corporate Officer,Owner,or Documented Designee Date <br /> Tt-AF-W <br />