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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: Louis Anderson <br /> Permittee Company: Jefferson County <br /> Address: 21401 Golden Gate Canyon <br /> Road <br /> Golden, CO 80403-8108 <br /> Phone Number: (303)271-5205 <br /> Fax Number: (303)271-5222 <br /> Email Address: <br /> Permitting Contact: Louis Anderson <br /> Company: Jefferson County <br /> Address: 21401 Golden Gate Canyon <br /> Road <br /> Golden, CO 80403-8108 <br /> Phone Number: (303)271-5206 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Louis Anderson <br /> Company: Jefferson County <br /> Address: 21401 Golden Gate Canyon <br /> Road <br /> Golden, CO 80403-8108 <br /> Phone Number: (303)271-5205 <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 /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />