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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: Jerry Johnston <br /> Permittee Company: Jerry Johnston <br /> Address: 13800 Hwy. 24 <br /> Box 99 <br /> Divide, CO 80814 <br /> Phone Number: (719)687-9043 <br /> Fax Number: <br /> Email Address: <br /> Permitting Contact: Jerry Johnston <br /> Company: Jerry Johnston <br /> Address: 13800 Hwy.24 <br /> Box 99 <br /> Divide, CO 80814 <br /> Phone Number: (719)687-9043 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Jerry Johnston <br /> Company: Jerry Johnston <br /> Address: 13800 Hwy. 24 <br /> Box 99 <br /> Divide, CO 80814 <br /> Phone Number: (719)687-9043 <br /> Fax Number: <br /> Email Address: <br /> 1,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 /> (�O I U- QLO-Lta S-�47 <br /> Signat of rmitt Cor orate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />