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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: -revf i red <br /> ��+�►� e � &1 <br /> Permittee Company: City of Fort Collins <br /> Address: 700 Wood Street <br /> P O Box 580 <br /> Fort Collins,CO 80522 <br /> Phone Number: <br /> -70-4f(o= 7-0 3 <br /> Fax Number: <br /> Email Address: Z#Wztsci=@fcgov.com <br /> u fi✓t <br /> I,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are <br /> being conducte in accordance with the Division approved mining and reclamation plans. <br /> 8 / 2a1� <br /> Signature of Permittee,Corporate Officer,O ner,or Documented Designee Date <br /> M-AF-04 <br />