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P 6/6 <br /> Division records indicate the fnllOwing permittee COMMA information_ If this information is not curre lease Page 5 of 5 <br /> n nt contact information: t,P tVe or print <br /> Pennittee Contact: I Jack Clark Jr <br /> I ! <br /> Pcrmittee Company. Jack Clark,Jr. <br /> P. 0. Box 767 <br /> i <br /> Silvemn,Co 81433 <br /> Phone Number. (970)387.5243 <br /> I <br /> Fax Number: (970)387-5121 <br /> Email Address: <br /> Q. <br /> L 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 /> Siguatum of Fermi ornarate Chge—er,C?wner,or u anted 5;—Signee Date <br />