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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 <br /> print current contact information: <br /> Permittee Contact: Mathew Valdez <br /> I cAG`c)•- <br /> Permittee Company: Costilla County <br /> Address: P.O. Box 130 <br /> San Luis, CO 81152 <br /> Phone Number: (719)672-9109 1 <br /> C7(66 9_ 7 <br /> - t L7-) <br /> Fax Number: <br /> Email Address: <br /> I,the undersigned,he -by st. - hat the information provided in this report is true and accurate, and that site operations are <br /> being conducted in a,core. - with the Division approved mining and reclamation plans. <br /> • <br /> Signature of Permittee,Corporate Offi er,Owner,or Documented Designee Date <br /> M-AF-04 <br />