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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: Andy Kagan <br /> Permittee Company: Rockbottom, LLC <br /> Address: 555 Ernest Avenue <br /> Westcliffe, CO 81252 <br /> Phone Number: (719)783-9636 <br /> Fax Number: <br /> Email Address: Akagan@centurytel.net <br /> Permitting Contact: Andy Kagan <br /> Company: Kagan& Sons <br /> Address: 555 Ernest Ave <br /> Westcliffe, CO 81252 <br /> Phone Number: (719)783-9636 <br /> Fax Number: (719)783-3039 <br /> Email Address: <br /> Inspection Contact: Andy Kagan <br /> Company: Kagan& Sons <br /> Address: 555 Ernest Ave <br /> Westcliffe, CO 81252 <br /> Phone Number: (719)783-9636 <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 /> Signature of Permittee Cor orate O ,Owner,or Documented Designee Date <br /> M-AF-01 <br />