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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: Jim Struble <br /> Permittee Company: N Colo Water Conservancy Dist. <br /> Address: 220 Water Avenue <br /> Berthoud, CO 80513 <br /> Phone Number: 9- <br /> '7o-(.ZZ -ZZ 3 <br /> Fax Number: (970)532-0942 <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 /> —,<� '-ee cx;�E� Z Z.W <br /> Signatur mittee r orate Officer,Owner,or Documented Designee Date <br /> M-AF-O <br />