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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: Bi11y$�1ac1— <br /> Dan Miller <br /> Permittee Company: Moffat County <br /> Address: P.O.Box 667 <br /> Craig,CO 81626 <br /> Phone Number: (970)824-3211 <br /> Fax Number: (970)824-0356 <br /> Email Address: <br /> Permitting Contact: Po%V4A44eerP--- Dan Miller <br /> Company: <br /> Address: 1570 Ranney Street PO Box 667 <br /> Craig,CO 81625 Craig, CO 81626 <br /> Phone Number: (95t 824-924-9�-- <br /> 970-824-3211 <br /> Fax Number: <br /> 970-824-0356 <br /> Email Address: dmiller@moffatcounty.net <br /> Inspection Contact: Nfervia N4@Qfe <br /> Dan Miller <br /> Company: <br /> Address: 13491ane)— PO Box 667 <br /> Qaiff, 0-8i6z6- Craig, CO 81626 <br /> Phone Number: <br /> 970-824-3211 <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 conduc7A- <br /> ordance with the Division approved mining and reclamation plans. <br /> 1/25/2017 <br /> Signature o Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M AF-04 <br />