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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: Sam Keeling <br /> Permittee Company: Sam Keeling <br /> Address: <br /> P O Box 361 <br /> LaVeta,CO 81055 <br /> Phone Number: (719)742-5557 <br /> Fax Number: <br /> Email Address: Samlaveta@earthlink.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 <br /> the Division approved mining and reclamation plans. <br /> "�r ?— <br /> Signature of Permittee,Corporate Of ,Owner,or Documented Desijznee Date <br /> M-AF-01 <br />