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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: Roger August <br /> Permittee Company: Mask Ranch, LLC <br /> Address: P.O. Box 5356 <br /> Pagosa Springs,CO 81147 <br /> Phone Number: (970)946-3074 <br /> Fax Number: l�', 1,A <br /> Email Address: <br /> v�ne� CIOt <br /> I,the undersigned,hereby state that the information provided in this report is true and accurate, and that site operations are <br /> bei onducted in ac ance with the Division approved mining and reclamation plans. <br /> / <br /> Sign ure of Permi a Corporate icer,Owner, r ocumen ed Designee ate <br /> M-AF-01 <br />