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Pa <br /> Division records indicate the following pennittee/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 curreal contact information: <br /> Permittee Contact: Suzanne M.Theisen <br /> Permittee Company: Theisen Mineral <br /> Address: 1251 Bailey Dr. <br /> Brighton,CO 80603 <br /> Phone Number. (303)659-2704 <br /> Fax Number. <br /> Email Address: <br /> Permitting Contact: <br /> U�0- <br /> Company: Theisen Mineral <br /> Address: 1251 Bailey Dr. <br /> Brighton,CO 80603 <br /> Phone Number. (303)659-2704 <br /> Fax Number: <br /> Email Address: <br /> tnspectlea Contact: <br /> cwA 6 S A , L oik c <br /> Company: Theisen Mineral (Q, 1 <br /> Address: aiiey-Br eta y'g S./ a �P� <br /> fitm' 4�3— <br /> Phone Number: 659-2?04- - <br /> o'7-Doaf-6l�v <br /> Fax Number: <br /> Email Address: COP <br /> a t , Co Qtl C x <br /> I,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are <br /> bein ductedtin Accordance with the Division approved mining and reclamation plans. <br /> yi, <br /> /n' <br /> Signature of Pe=Corporate Officer.Owner or m Desi nee Date <br /> *A.I <br />