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i <br /> 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: $ sort <br /> Permittee Company: Montrose County <br /> Address: 949 N. 2nd Street <br /> Montrose, CO 81401 <br /> Phone Number: <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 accordanqeVith the Division approved mining and reclamation plans. <br /> A, �.I),IA- <br /> O -z'17 <br /> Signat e o Permittee, orporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />