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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: . <br /> u <br /> Permittee Company: Medicine Bow - Routt National <br /> Forest USDA Forest Service <br /> Address: 2468 Jackson St. <br /> Laramie,WY 82070-6535 <br /> Phone Number: <br /> Fax Number: (307)745-2398 <br /> Email Address: . <br /> � tM �cc ✓�S � cCS. �r.C�. v5 (/ <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 /> q 20 9� <br /> Signature of Permittee,Coruorate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />