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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: -acgu Goommer <br /> pE-t-E Gatv\A <br /> Permittee Company: L.Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta,CO 81055 <br /> Phone Number: (719)742-334.0 <br /> 7/q-74/z-5//3 <br /> Fax Number: <br /> Email Address: <br /> Permitting Contact: Magee-Feemnter PGCe 4$'e, <br /> Company: L.Otto Goemmer <br /> Address: P.O.Box 165 <br /> La Veta,CO 81055 <br /> Phone Number: ( - 42-3(r1 <br /> 7/9-7y2—, 7 3 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: 41effeAelet7re <br /> Company: L.Otto Goemmer <br /> Address: P.O. Box 165 <br /> La Veta,CO 81055 <br /> Phone Number: <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 /> (>' ff. crevyyrYLA - <br /> Signs e o Pe ittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-0I <br /> ' c q 12_9 <br />