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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: Dean Ormiston <br /> Permittee Company: Baca County <br /> Address: 741 Main St.,Suite 1 <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> 71 9- 5-7--q-3 30 <br /> Fax Number: (719)523-6584 <br /> Email Address: ormiston@bacacountyco.gov <br /> I,the undersigned, hereby state that e i formation provided in this report is true and accurate, and that site operations are <br /> being din accordance wit th vision approved mining and reclamation plans. <br /> 5- <br /> Signatuile of ker e tgfAraAfficer,Owner,or Documented Designee Date <br /> M-AF-04 <br />