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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: Marcy Brossman <br /> Permittee Company: Cheyenne County <br /> Address: P.O. Box 567 <br /> Cheyenne Wells,CO 80810 <br /> Phone Number: (719)767-5872 <br /> Fax Number: (719)767-5753 <br /> Email Address: Ccadmin@rebeltec.net <br /> rebeltec.net <br /> Permitting Contact: Marcy Brossman <br /> Company: Cheyenne County <br /> Address: P.O.Box 567 <br /> Cheyenne Wells,CO 80810 <br /> Phone Number: (719)767-5872 <br /> Fax Number: (719)767-5753 <br /> Email Address: <br /> Inspection Contact: Don Esarey Mike Engelbrecht <br /> Company: Cheyenne County <br /> Address: P.O. Box 567 <br /> Cheyenne Wells,CO 80810 <br /> Phone Number: (719)767-5872 <br /> 719-342-9493 <br /> Fax Number: (719)767-5853 <br /> 719-767-5753 1/ <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 /> ..(n Ant&'i6& fii r <br /> Signature oV ermittee,Corporate Officer,O her,or Documented Designee Date <br /> M-AF-04 <br />