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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 print <br />current contact information: <br />Permittee Contact: <br />Jordan C. Burdick <br />Permittee Company: <br />Jordan C. and Jone L. Burdick <br />Address: <br />P-A-Bur-rM <br />7,b� <br />do U <br />Phone Number: <br />(303) 823-5943 <br />d— <br />Fax Number: <br />Email Address: <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 />I <br />to <br />gignature of Permittee, Corporate Officer, Owner, or Documented Desi nce Date <br />M AF 11 0 A the <br />�..J L���/j fit!► <br />1 / f U% -,1vT4 )',V S -� t. ��u li L c%s 4?14 e <br />