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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: Brad Palmer <br /> Permittee Company: Lake County <br /> Address: P.O. Box 952 <br /> Leadville,CO 80461 <br /> Phone Number: (719)486-0259 <br /> Fax Number: (719)486-8479 <br /> Email Address: n /1LAC r, �S �� l c(,��/�` <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 /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />