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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 />Contact: I Lex <br />Address: 1 13 West 3rd St., Room 208 <br />La Junta, CO 81050 <br />(719) 383-3035 <br />Fax Number: <br />Email Address: Lnichols@oterogov.org <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 ap + �� cd mining and reclamation plans. <br />Signature of Permittee, Itorporallr Officer. Owner, or Documented Designee Date <br />M -.AF -04 <br />