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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: Clay Kimrni <br /> Permittee Company: Weld County Public Works <br /> Address: 1111 H St. <br /> Greeley, CO 80632 <br /> Phone Number: (970)304-6496 <br /> Fax Number: (970) 304-6497 <br /> Email Address: Ckimmi@co.weld.co.us <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 in accordance with the Division approved mining and reclamation plans. <br /> OL 1 7/i9/ 1(i <br /> Signaturcilof Permittee, Corporate Officer, Owner,or Documented Designee Date <br /> M-AF-04 <br />