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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: Peter L. Dawson <br /> Permittee Company: Baca County <br /> Address: 741 Main St.,Suite 1 <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: (719)523-6584 <br /> Email Address: � ry Jur <br /> cU <br /> I,the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br /> being conducte in accordance ' the Division approved mining and reclamation plans. <br /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> NI-AF-04 <br />