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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: Larry L. Chartier <br /> Permittee Company: Larry L Chartier <br /> Address: 21305 Road 28.5 <br /> Brush, CO 80723 <br /> Phone Number: (970) 842-5657 <br /> Fax Number: <br /> Email Address: <br /> Permitting Contact: <br /> Company: Larry L Chartier <br /> Address: 21305 Road 28.5 <br /> Brush, CO 80723 <br /> Phone Number: (970)842-5657 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: <br /> Company: Larry L Chartier <br /> Address: 21305 Road 28.5 <br /> Brush, CO 80723 <br /> Phone Number: (970)842-5657 <br /> Fax Number: <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 /> Signature of Permittee Clorpirate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />