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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: Cathleen Van Egmond <br /> Permittee Company: Russ Van Egmond <br /> Address: 546 Doe Valley Rd. <br /> Guffey,CO 80820 <br /> Phone Number: (719)689-0877 <br /> Fax Number: (719)689-5889 <br /> Email Address: Cathleenmore@aol.com <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 /> I— d � 0 zlii2:L �� I-� )-� <br /> Si nat e o ermittee Corporate r,Owner,or Documented Designee Date <br /> M-AF-01 <br />