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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: Mike L.Koellner <br /> Permittee Company: Mike L.Koellner dba L&L <br /> Ready Mix <br /> Address: 810 South Colorado <br /> P.O. Box 218 <br /> Haxtun,CO 80731 <br /> Phone Number: (970)774-6114 <br /> Fax Number: (970)774-6115 <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 /> .." 0� � / L� <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />