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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: Brian Busse <br /> Permittee Company: Brian Busse <br /> Address: 1437 G St. <br /> Salida, CO 81201 <br /> Phone Number: <br /> -a 3V-(0096 <br /> Fax Number: <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 /> ,,,.._ L 7 1 -.:2 ® f Z <br /> Signature of Permittee,Corporate Officer,Owner,or Documented DesiEnee Date <br /> M-AF-02 <br />