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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: Thomas O'Rourke <br /> Permittee Company: O'Rourke Excavating,Inc. <br /> Address: 2489 CR 15 <br /> South Fork,CO 81154 <br /> Phone Number: (719)580-9602 <br /> Fax Number: <br /> Email Address: Orourkeexcavating@hotmail.com <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 Div' ion approved mining and reclamation plans. <br /> Signature of Permittee,Corporate fficer,Owner,or Documented Designee Date <br /> WAF-Ot <br />