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Page 5 of 5 <br /> <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 /> <br />Permittee Contact: <br /> <br />Suzanne M. Theisen <br />Permittee Company: <br /> <br />Theisen Mineral <br />Address: <br /> <br /> <br /> <br />1251 Bailey Dr. <br />Brighton, CO 80603 <br /> <br />Phone Number: <br /> <br />(303) 659-2704 <br />Fax Number: <br />Email Address: <br />Permitting Contact: <br /> <br />James J. Theisen <br />Company: <br /> <br />Theisen Mineral <br />Address: <br /> <br /> <br /> <br />1251 Bailey Dr. <br />Brighton, CO 80603 <br /> <br />Phone Number: <br /> <br />(303) 659-2704 <br />Fax Number: <br />Email Address: <br />Inspection Contact: <br /> <br />James J. Theisen <br />Company: <br /> <br />Theisen Mineral <br />Address: <br /> <br /> <br /> <br />1251 Bailey Dr. <br />Brighton, CO 80603 <br /> <br />Phone Number: <br /> <br />(303) 659-2704 <br />Fax Number: <br />Email Address: <br /> <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 /> <br /> <br /> <br />Signature of Permittee, Corporate Officer, Owner, or Documented Designee Date <br />M-AF-01