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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: Forrest Neuerburg <br /> Permittee Company: City of Monte Vista <br /> Address: 95 W, 1st <br /> Monte Vista, CO 81144 <br /> Phone Number: (719) 852-2692 <br /> Fax Number: (719) 852-6161 <br /> Email Address: Roberts@co.monte-vista.co.us <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 /> /oA,; 0/ <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee bafe <br /> M-AF-04 <br />