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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: Michael Iguchi <br /> Permittee Company: Keyah Grande Lodge and Elk <br /> Ranch <br /> Address: 13211 Highway 160 West <br /> Pagosa Springs, CO 81147 <br /> Phone Number: (970)731-2158 <br /> Fax Number: (970)731-5446 <br /> Email Address: Cllr� 1, <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..i�n cord ce with the Division approved mining and reclamation plans. <br /> Signature of Permit a Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />