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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: Mark Gardner <br /> Permittee Company: Ephemeral Resources,LLC <br /> Address: P.O. Box 1769 <br /> Grand Junction, CO 81502 <br /> Phone Number: (970)242-7538 <br /> Fax Number: (970)242-1851 <br /> Email Address: Whiteh2o@acsol.net <br /> Permitting Contact: Tlw <br /> Company: Ephemeral Resources,LLC <br /> Address: "'�7:h St X 7 6 <br /> Phone Number: (924�� <br /> 470-2 y z-753�i- r� <br /> Fax Number: (979j 2 s i5 G,70_,2 _j j <br /> Email Address: ) <br /> wN: � t- ��a �w�so ,ri1° ✓ <br /> Inspection Contact: —T-01� <br /> Company: Ephemeral Resources, LLC <br /> Address: IQ 9 4t _St <br /> r j 7� <br /> 1501 x <br /> Phone Number: ( (?70_ Z YZ <br /> Fax Number: ( - <br /> 97�._ <br /> Email Address: 1l I <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 /> n 3-31-/7 <br /> Signature of Per ittee,Corporate Officer,Owner,or bocumented Desienee Date <br /> M-AF-01 <br />