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Page 5 of 5 <br /> Division records indicate the following permittee contact information. If this information is not current,please type or print <br /> current contact information: <br /> Permittee Contact: -Mathewt,:VWdez- _ <br /> Permittee Company: Costilla County <br /> Address: P.O.Box 130 <br /> San Luis,CO 81152 <br /> Phone Number: (719)672-9109 <br /> Fax Number: (719)672-3003 <br /> Email Address: Mathew.valdez@costillacounty- <br /> co.gov <br /> 1,the undersigned,hereby state that t information provided in this report is true and accurate,and that site operations are <br /> being conducte in accordance t e Division approved mining and reclamation plans. <br /> Signature o -ittee.Coruorate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />