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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: Wallace F.Burtis <br /> Permittee Company: Wallace F. Burtis <br /> Address: 66 Dartmouth Ave. <br /> Pueblo, CO 81005 <br /> Phone Number: (719)566-1669 <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 accordance with the Division approved mining and reclamation plans. <br /> /P�� o- 13 <br /> Signature of Permittee, Corporate Officer, Owner,or Documented Designee Date <br /> M-AF-02 <br />