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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: Ignacio Vasquez Sr <br /> Permittee Company: Ignacio Vasquez Sr. <br /> Address: P.O. Box 938 <br /> Lyons, CO 80540-0938 <br /> Phone Number: (303) 823-5684 <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 accordance with the Division approved mining and reclamation plans. <br /> � r <br /> Signs of Permittee C e Officer, Owner,or Documented Designee Date <br /> M-AF-01 <br />