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Page 5 of 5 <br /> Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have <br /> information on record). If this information is blank or not current,please type or print current contact information: <br /> Permittee Contact: r <br /> ly <br /> Permittee Company: Elbert County <br /> Address: P.O.Box 116 <br /> Kiowa, CO 80117 <br /> Phone Number: (303) 621-3157 <br /> Fax Number: (303) 621-3159 <br /> Email Address: <br /> Permitting Contact: Tim 41er-ww1 <br /> Company: Elbert County <br /> Address: 809 Ute Ave. <br /> Simla, CO 80835 <br /> Phone Number: (719)541-2268 <br /> Fax Number: (303) 621-3166 <br /> Email Address: <br /> Inspection Contact: <br /> Company: Elbert County <br /> Address: 809 Ute Ave. <br /> Simla, CO 80835 <br /> Phone Number: (719) 541-2268 <br /> Fax Number: <br /> Email Address: <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 /> %natur' of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />