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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: Randy Schafer <br /> Permittee Company: Phillips County <br /> Address: 221 S. Interocean Ave. <br /> Holyoke,CO 80734 <br /> Phone Number: (970)854-3778 <br /> Fax Number: (970)854-3811 <br /> Email Address: Randy.schafer@phillipscounty.co <br /> Permitting Contact: Randy Schafer <br /> Company: Phillips County <br /> Address: 221 S. Interocean Ave. <br /> Holyoke, CO 80734 <br /> Phone Number: (970)854-3778 <br /> Fax Number: 4 ,:15S� <br /> Email Address: Randy.schafer@phillipscounty.co <br /> Inspection Contact: Randy Schafer <br /> Company: Phillips County <br /> Address: 221 S. Interocean Ave. <br /> Holyoke, CO 80734 <br /> Phone Number: (970)854-3778 <br /> Fax Number: Q10 S54 ��« <br /> Email Address: Randy.schafer@phillipscounty.co <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 /> 3✓ /� S / 7 <br /> Signature Permittee or orate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />