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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: William K.Havengar <br /> Permittee Company: Lazy H Inc <br /> Address: 34449 County Road 10 <br /> Keenesburg,CO 80643 <br /> Phone Number: (303)434-6650 <br /> Fax Number: (303)732-4568 <br /> Email Address: $1 ` Lei 5 H'8ra�,cl <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 /> S�u1 J u kp— a_i ,9010 <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />