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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: _ J _ i�' / 00 Y,-- <br /> Permittee Company: Elbert County <br /> Address: P.O. Box 116 <br /> Kiowa, CO 80117 <br /> Phone Number: (303)621-3157 <br /> Fax Number: (303)621-3159 <br /> Email Address: TY- MAN-VM006.0 ejlb-er p -Co. `/ <br /> CO.GOV <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 /> :Z— a& /'Clber t �' c�.►f, a <br /> Signatuille"of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />