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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: Justin T.Hersh <br /> Permittee Company: Larimer County <br /> Address: P.O.Box 1190 <br /> Fort Collins, CO 80522 <br /> Phone Number: (970)498-5662 <br /> Fax Number: (970)498-5678 <br /> Email Address: Hershjt@larimer.org <br /> Permitting Contact: Dale L.Miller -Too p Ck�f-�,Czf� <br /> Company: Larimer County <br /> Address: P.O.Box 1190 <br /> Fort Collins, CO 80522 <br /> Phone Number: (970)498-5653 <br /> Fax Number: COO WAS? S(P-7V <br /> Email Address: Juc -qtn+@ Ioxvwk c.Orc� <br /> Inspection Contact: Dale L.Miller <br /> --row) c�uERC�N`� <br /> Company: Larimer County <br /> Address: P.O.Box 1190 <br /> Fort Collins, CO 80522 <br /> Phone Number: (970)498-5653 <br /> Fax Number: Ot 70 yQ <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 /> r 3 <br /> Signature of Permittee,Cor ate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />