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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 <br /> print current contact information: <br /> Permittee Contact: EddieClayton <br /> Permittee Company: Eddie Clayton <br /> Address: P.O. Box 2 <br /> Hooper,C081136 <br /> Phone Number: (719)378-2392 7 Z/ <br /> Fax Number: <br /> Email Address: CO g9rj <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 /> ? -//-1-/7 <br /> Signature ofPermi ,Corporite Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />