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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: a " -____ ey Ced <br /> Permittee Company: L. Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta, CO 81055 <br /> Phone Number: X194 742.34314- <br /> 7/9 -si/3 )eve Mes$10_. <br /> Fax Number: <br /> Email Address: <br /> Permitting Contact: r <br /> Company: L. Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta,CO 81055 <br /> Phone Number: <br /> 7/9- 74Z-57/3 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: —4acqua.Cepoommer <br /> pE-t t rr wr{t2 <br /> Company: L. Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta,CO 81055 <br /> Phone Number: 441443•5412692561-- <br /> 7/9—7 ifiz <br /> 93•5412692561--7/9-7`/z `5//3 <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 /> •Cri-47) EA-10-, 7 <br /> Signature of ermitte ,Cblfporate Officer,Owner,or Documented Designee Date <br /> M-AF-0 1 <br />