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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: Rob Englehart <br /> Permittee Company: Montezuma County <br /> Address: 1680 North Dolores Road <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: Road@montezuma.co.us <br /> Permitting Contact: Ue EA'Op- / <br /> R o <br /> Company: Montezuma ounty <br /> Address: 1680 North Dolores Road <br /> Cortez, CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: <br /> Inspection Contact: IS <br /> Rob �-- <br /> Company: Montezuma C unty <br /> Address: 1680 North Dolores Road <br /> Cortez,CO 81321 <br /> Phone Number: (970)565-8666 <br /> Fax Number: (970)565-8252 <br /> Email Address: <br /> • 1J�S <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 /> 0a /0 1 <br /> Signature of P—ermlike, rate hfficer,Owner,or Documented Designee Date <br /> M-AF-04 <br />