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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: <br />Marcy Brossman <br />Permittee Company: <br />Cheyenne County <br />Address: <br />P.O. Box 567 <br />Cheyenne Wells, CO 80810 <br />Phone Number: <br />(719) 767-5872 <br />Fax Number: <br />(719) 767-5753 <br />Email Address: <br />Ccadmin@rebeltec.net <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 />oft' mittee, Cornarate Officer, Owner, or Documented Desienee Dale <br />M -arm, <br />