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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: Steve DeCamillo <br /> Permittee Company: City of Cripple Creek <br /> Address: 337 E. Bennett Ave. <br /> P.O. Box 430 <br /> Cripple Creek, CO 80813 <br /> Phone Number: (719)689-2125 <br /> Fax Number: (719)689-0121 <br /> Email Address: <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, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />