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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: Dale Kort <br /> o eTv?-Go) ��ZoANI St3E�F� ��.D <br /> Permittee Company: Forest Lakes Metro District <br /> Address: P.O.Box 440 <br /> Bayfield, CO 8 1 1 22-0440 <br /> Phone Number: (970) 884-2925 <br /> Fax Number: (970) 884-0305 <br /> Email Address: FLMD@FLMD.com <br /> Permitting Contact: Dale Kortz <br /> s+4 Ems-, <br /> Company: Forest Lakes Metro District <br /> Address: P.O. Box 440 <br /> Bayfield,CO 8 1 1 22-0440 <br /> Phone Number: (970) 884-2925 <br /> Fax Number: (970) 884-0305 <br /> Email Address: FLMD@FLMD.com <br /> Inspection Contact: Dale Kortz ?�R;AN <br /> SHE r=r UQ <br /> Company: Forest Lakes Metro District <br /> Address: P.O. Box 440 <br /> Bayfield, CO 81122 <br /> Phone Number: (970) 884-2925 <br /> Fax Number: q—7D _ S SLI _ 6 30-5 <br /> Email Address: FLMD@FLMD.com <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 /> �P^'�E rj1:--L- IZ I�0 O�Q <br /> Signature of Permittee Cor orate fi ,Owner,or Documented Designee D to <br /> M-AF-04 <br />