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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: Ken 111'41�� <br /> 1-1 — v <br /> Permittee Company: Montrose County <br /> Address: 949 N. 2nd Street <br /> Montrose, CO 81401 <br /> Phone Number: <br /> Fax Number: c4�m 2n n ✓ <br /> eD <br /> Email Address: <br /> Permitting Contact: 43=�� , <br /> Company: ch,Inc: <br /> Address: - <br /> Phone Number: E - <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Norm David <br /> Company: Montrose County <br /> Address: 949 N 2nd Street <br /> Montrose, CO 81401 <br /> Phone Number: (970)209-8329 <br /> Fax Number: (970)252-7010 <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 /> L 2 �A, 41111, <br /> SigAfiture of Permittee, orporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />