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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: George E.Otten <br /> Permittee Company: George E. Otten <br /> Address: 11438 CR 19 <br /> Fort Lupton, CO 80621 <br /> Phone Number: (970)785-2538 <br /> Fax Number: (970)785-6248 <br /> Email Address: Gotten7386@aol.com <br /> I,the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br /> bein 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-02 <br />