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f <br /> 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: Steve Williams <br /> Permittee Company: Washington County <br /> Address: 11920 Co. Rd. CC <br /> P.O. Box 32 <br /> Anton,CO 80801 <br /> Phone Number: (970)383-2216 <br /> Fax Number: (977)038-3221 <br /> Email Address: <br /> Permitting Contact: Randy Scjafer <br /> Company: <br /> Address: 40586 County Rd.21 <br /> Haxtun, CO 80731 <br /> Phone Number: (970)854-3778 <br /> Fax Number: (970)854-3811 <br /> Email Address: <br /> Inspection Contact: Steve Williams <br /> Company: Washington County <br /> Address: 11920 Co.Rd. CC <br /> P.O. Box 32 <br /> Anton, CO 80801 <br /> Phone Number: (970)383-2216 <br /> Fax Number: (970)383-2213 <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 /> / zr�q4z,4)&- 0 <br /> S <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />