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Page 6 of 6 <br /> Division records indicate the following permittee/landowner contact information. If this information is not current,please <br /> type or print current contact information: Rule 5.6.1(a,b). <br /> Permittee Contact: Ann Lemberg <br /> Permittee Company: Golden Age Number Two <br /> Mining Co <br /> Address: P.O. Box 6079 <br /> Denver, CO 80206 <br /> Phone Number: (303)363-9145 <br /> Fax Number: <br /> Email Address: Goldenliberty@aol.com <br /> Landowner Contact: <br /> Landowner Address: <br /> Landowner Phone <br /> Number: <br /> Landowner Email <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 NOI and reclamation plans. Rule 5.6.1(h). <br /> Signature of Permittee, Corporate Officer,Owner,or Documented Designee Date <br /> P-AF-01 <br />