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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: Harold E. Clare, lI <br /> Permittee Company: The Clare Corporation <br /> Address: P.O. Box 1 <br /> Florissant,CO 80816 <br /> Phone Number: (719) 748-3805 <br /> Fax Number: (719) 748-5120 <br /> Email Address: Acconcrete@usa.net <br /> 1,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 /> NI-AF-01 <br />