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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: '4eteettle+h,etrffNer <br /> PetE Gslekr kora <br /> Permittee Company: L. Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta, CO 81055 <br /> Phone Number: 41,61).74,i•-334.19- <br /> 7i7-7Y -5-2/.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 /> 89/7 <br /> Sig natuile o 'ermitt , Corporate 0 icer,Owner,or Documented Designee Date <br /> M-AF-01 <br />