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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: Rob Englehart <br /> Permittee Company: Montezuma County <br /> Address: 1680 North Dolores Road <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: Renglehart@co.montezuma.co.us <br /> Permitting Contact: T,m"Arr^mom <br /> Company: Montezuma Cbunty <br /> Address: 1680 North Highway 145 <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: <br /> Inspection Contact: T-irtHyfeean1b <br /> Company: Montezuma Oounty <br /> Address: 1680 North Highway 145 <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: <br /> ¢n ft S <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 /> 2n�' "7 �<-�\\ 't LZA-%'�& — — /'?—/ <br /> Signature of Per mitt Cor ora a Officer.Owner,or Documented Designee Date <br /> M-AF-04 <br />