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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: Levi Schlosser <br /> Permittee Company: Schlosser Incorporated <br /> Address: 755 Hwy 385 <br /> Burlington, CO 80807 <br /> Phone Number: (719)346-8806 <br /> Fax Number: 7/? <br /> f?341& _ 0$3 <br /> Email Address: Dnr-drmsrninadmin@state.co.us , <br /> Permitting Contact: Levi Schlosser <br /> Company: Schlosser Incorporated <br /> Address: 755 Hwy 385 <br /> Burlington,CO 00000 <br /> Phone Number: (719)346-8806 <br /> Fax Number: 71 f- '3 b <br /> Email Address: Dnr-drmsminadmin@state.co.us <br /> Inspection Contact: Levi Schlosser <br /> Company: Schlosser Incorporated <br /> Address: 755 Hwy 385 <br /> Burlington,CO 99990- <br /> go�o <br /> Phone Number: (719)346-8806 <br /> Fax Number: f <br /> 7j?- '3 uG- ks g <br /> Email Address: Dnr-drmsminadmin@state.co.us <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 /> �/A / <br /> Sign re of Permittee. ornorate Officer,Owner,or Documented Designee D to <br /> M-AF-01 <br />