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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 <br /> print current contact information: <br /> Permittee Contact: Peter L.Dawson <br /> Permittee Company: Baca County <br /> Address: 741 Main St.,Suite 1 <br /> Springfield, CO 81073 <br /> Phone Number: (719) 523-6532 <br /> Fax Number: (719) 523-6584 <br /> Email Address: Pdawson@bacacountyco.gov <br /> 1,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are <br /> being conducted i ccordance wit Division approved mining and reclamation plans. <br /> //12U/ <br /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br /> l <br />