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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: <br />Brad Palmer <br />Permittee Company: <br />Lake County <br />Address: <br />P.O. Boa 952 <br />Leadville, CO 80461 <br />Phone Number: <br />(719) 486-0259 <br />Fax Number: <br />(7119) 4861-884779 <br />Email Address: <br />/ nn <br />Fc11Mc1 00. AK lips« <br />rrh <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />being condueted�n Accordance with the Division approved mining and reclamation plans. <br />Owner, or Documented Desienee Date <br />M -AF -a <br />