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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: John M.Everitt <br /> Permittee Company: John M.Everitt <br /> Address: 24274 CR 17 <br /> Haxtun, CO 80731 <br /> Phone Number: (970)774-7508 <br /> Fax Number: <br /> Email Address: Johneveritt63@gmail.com <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 /> 0/ <br /> -Z -/� <br /> Signature ermittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />