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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: R. Lewis Fillmore <br /> Permittee Company: R. Lewis Fillmore <br /> Address: P O Box 258 <br /> j <br /> Boone, CO 81025 v V I& CO <br /> Phone Number: (719) 568-6712 <br /> Fax Number: <br /> Email Address: Ronfill@hotmail.com <br /> 1,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 /> a&'TZa" -' 2!Z'�(c <br /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />