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Page 5 of 5 <br /> <br />Division records indicate the following permittee contact information. If this information is not current, please type or pr int <br />current contact information: <br /> <br />Permittee Contact: <br /> <br />Thomas F. Latham <br />Permittee Company: <br /> <br />Thomas F & Ginger L Latham <br />Address: <br /> <br /> <br /> <br />P.O. Box 66 <br /> <br />DeBeque, CO 81630 <br /> <br />Phone Number: <br /> <br />(970) 283-5633 <br />Fax Number: <br />Email Address: <br /> <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 /> <br /> <br /> <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date <br /> <br />M-AF-01