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Page 5of5 <br /> Division reconis indicate the following pezmittee;andowner cnntml information(blf elds indicatethat we r4onot have <br /> information on record). If this information is blank or not current,please type or print current contact information: <br /> IP ri I ADeaW Was # { <br /> I'PerniftweVornpanc yriiinutaili <br /> Address: P.O.Box 100 <br /> Eads,CO 81036 <br /> Phone Number: (719)438-5810 <br /> Fax Number: (719)438-5615 <br /> Email Address: Commissioners@kiowacountycolo.com <br /> Permitting Contact: Allen Watts <br /> Company: Kiowa County <br /> Address: P.O.Box 100 <br /> Eads, CO 81036 <br /> Phone Number: (719)438-5810 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Allen Watts <br /> Company: Kiowa County <br /> Address: P.O. Box 591 <br /> Eads, CO 81036 <br /> Phone Number: (719)438-5810 <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 /> U30—/C3 -3 -4 /2 <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />