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3 <br /> 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: Patricia M.Farnsworth <br /> Permittee Company: Farnsworth Construction and Gravel <br /> Company <br /> Address: 175 Hwy 133 <br /> Paonia,CO 81428 <br /> Phone Number: (970)527-4434 <br /> Fax Number: (970)527-5522 <br /> Email Address: Farnsworthconstructiongravel@gmail.com <br /> Permitting Contact: Patricia M.Farnsworth <br /> Company: Farnsworth Construction and Gravel <br /> Company <br /> Address: 175 Hwy 133 <br /> Paonia,CO 81428 <br /> Phone Number: (970)527-4434 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Patricia M.Farnsworth <br /> Company: Farnsworth Construction and Gravel <br /> Company <br /> Address: 175 Hwy 133 <br /> Paonia,CO 81428 <br /> Phone Number: (970) 527-4434 <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 /> Signature of Permittee, orpo ate Officer,Owner,or Documented DesiLmee Date <br /> M-A F-01 <br />