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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: Mason King <br /> Permittee Company: Mason King <br /> Address: P.O. Box 68 <br /> Cope, CO 80812 <br /> Phone Number: (970) 357-4245 <br /> Fax Number: <br /> Email Address: <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 accorda ce w*the Division approved mining and reclamation plans. <br /> Signature o Permittee Cor or a Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />