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Page 5 of5 <br />Divisionrecordsindicatethe following permittee/landowner contact information (blank fields indicatethat wedo nothave <br />information on record).Ifthis information isblankornot current,pleasetypeor print current contact information: <br />Permittee Contact:Trent Stafford <br />Permittee Company:Seifert Enterprises, LLC <br />Address:198 Rangeview Loop <br />Westcliffe,CO 81252 <br />Phone Number:(719)783-2757 <br />Fax Number: <br />7/1-7M-AW <br />Email Address:Ap.admin@sbcompanies.com <br />Permitting Contact:Ken Klco <br />iCtoJr H-ejudn <br />Company:Azurite,Inc <br />Ser-fer+£rrf«*ri&*S U- <br />Address:P.O.Box 338 <br />Cotopaxi,CO 81223 <br />\*\2 (Zasyae VV^co Loop <br />Phone Number:(719)942-4178 <br />li<i-IP?)-2tfS~7 <br />Fax Number:(719)942-4178 ll°t~-7^3-MM <br />Email Address:dp.aJnifn <0 sbcomfbnte <br />Inspection Contact:Trent Stafford KwJT 3£«lcA <br />Company:Seifert Enterprises, LLC <br />Address:198 Rangeview Loop <br />P.Oi Roy 710^ <br />l^B fio^ef \/Ceto Loop <br />U/tfSfe.lwft',CO &l^s>Westcliffe,CO 81252 <br />Phone Number:(719)783-2757 <br />Fax Number:-iw-ita-<2<t$x <br />Email Address:c\p.oAm»n (j)£&coanp<xni*S-co<n <br />I, the undersigned, hereby state] <br />being conducted in, <br />hatthe information provided in this report istrueand accurate,andthatsite operations are <br />[ion approved miningand reclamationplans. <br />Signature of Permittee, Corporate Officer. Owner, or DocumentedDesignee <br />M-AF-01 <br />Date