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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: Clay Kimmi <br /> Permittee Company: Weld County <br /> Address: I I I I H St. <br /> P.O. Box 758 <br /> Greeley, CO 80632 <br /> Phone Number: (970)356-6496 <br /> Fax Number: (970)304-6497 <br /> Email Address: Ckimmi@co.weld.co.us <br /> Permitting Contact: Clay Kimmi <br /> Company: Weld County <br /> Address: 1111 H Street <br /> P.O. Box 758 <br /> Greeley, CO 80632 <br /> Phone Number: (970)304-6496 <br /> Fax Number: (970)304-6497 <br /> Email Address: Ckimmi@co.weld.co.us <br /> Inspection Contact: Jay McDonald <br /> Company: Weld County <br /> Address: 1111 H Street <br /> P.O. Box 758 <br /> Greeley, CO 80632 <br /> Phone Number: (970)304-6496 <br /> Fax Number: (970)304-6497 <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 /> OL 4nird ?/d7/17 <br /> Signat a of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />