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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: Glen R. Ausmus <br /> Permittee Company: Baca County <br /> Address: 741 Main St.,Suite I <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: (719)523-6584 <br /> Email Address: Sausmus@bacacountyco.gov <br /> Permitting Contact: Ray Miller <br /> Company: Baca County <br /> Address: 741 Main St. <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: — <br /> Email Address: <br /> Inspection Contact: Ray Miller <br /> Company: Baca County <br /> Address: 741 Main St. <br /> Springfield,CO 81073 <br /> Phone Number: (719)523-6532 <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 /> 1c�iC1-2 <br /> - % --2.o r <br /> Signature of Permittee,Corvorate Officer,Owner,or Documented Designee Date <br /> M-AP-04 <br />