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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: Glen R.Ausmus <br /> Permittee Company: Baca County <br /> Address: 741 Main St.,Suite 1 <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: (719)523-6584 <br /> Email Address: Sausmus@bacacountyco.gov <br /> Permitting Contact: Ray Miller <br /> Company: Baca County <br /> Address: 741 Main St. <br /> Springfield, CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: (719)523-6584 <br /> Email Address: <br /> Inspection Contact: Jack Carson <br /> Company: Baca County <br /> Address: 311 Main St. <br /> Two Buttes, CO 81073 <br /> Phone Number: (719)326-5921 <br /> Fax Number: (719)523-6584 <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 /> ,4- L ,P _ CZ� �L y - �2-y -Z� � <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />