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Page 5 of*5 <br /> I)ik I"ion It cm( s i"dica(c Ihr lollowin),petntiltce/landowner('()"fact iIIIor'naIiou(plank IielLIS indicate Ilia we do tint have <br /> inlointalion nn IccOid). II'lliis inIottnation is blank or not current, please type or print current contact information: <br /> I'ct"lilt►e (',ntlacl: (ivvctt IUillcy �— <br /> I'ctniillcc l'untp:nt�: cys Sand &. Oavel' . <br /> �1d,h�•�.�,: 19-II I?dnnuuls SI � � _ 4 <br /> P 11 Ilox I25 alp► �� ,z,4;- .l,r <br /> it ush, ('O xl l 121 <br /> I'luni, tlunil,ct - (i00) <br /> I.nriil /�ddica: I)in ►It nisntinadnti"ru�raale.co.us --- ----- <br /> I'ct niillin)!('oulacl: (nvcn Oillev ------ ---------- ---- <br /> l'o11111mi!: Oillcys Sand navel - ---- <br /> Ad lics`: 19H Fdontnds tit <br /> 1'O Box 125 <br /> Itii,sh, CO 811721 <br /> I'liun, tJunilu t: (970) 8-12-281() - - — ------ ---`- --- <br /> I a� IJnntlu•i: - <br /> io;iil Addtc"": - - Ulu dittt�niinadi"iniri�;lale.co.u5 <br /> n�pcclinn ("ontacl: Gwen I)illcy <br /> I)illcys Sand Glavel -- -- -- <br /> I'.O. Ilox 125 <br /> Iltosh, (•l) 80721 <br /> I'lu,"c tJutnl,ct: (9711) 8,12-28111 - -- .. — -- — <br /> I. Ow n"d,•i .il m d. lit' <br /> rzIa(c Oro the i"li►tntafion ptov�ided in this tepott is true and accurate, and Iltat site operations are <br /> I,;inl �•ndn, I,•d in :1, ,�otd:nlce � ilh (Ile I)i\i'Jon approved mining and teclatuation plan~. <br /> tiit!naltn e of Perntillcc, Cot ttot:Ile 0I leer,()it ner,or_Documented DesiL;nee Date <br />