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Page s of3 <br />Divisionrecm&indic2dethefoliowingpmn tteeliandowner contarL infonnation (blank -fields. indiude-th-&-we fid -nal have <br />information on record). If this information is blank or not current, please type or Print current contact information: <br />Permittee Contact: <br />Patricia Farnsworth <br />Permittee Company: <br />Farnsworth Construction and Gravel <br />Com an <br />Address: <br />175 Hwy 133 <br />Paonia, CO 81428 <br />Phone Number: <br />(970) 5274434 <br />Fax Number: <br />(970) 527-5522 <br />Email Address: <br />amsworthconstructiongravel@gmail.com <br />Permitting Contact: <br />Patricia Farnsworth <br />Company: <br />Farnsworth Construction and Gravel <br />Company <br />Address: <br />1425 4005 Ln <br />Paonia, CO 81428 <br />Phone Number: <br />(970) 5274434 <br />Fax Number: <br />Email Address: <br />Inspection Contact: <br />Patricia Farnsworth <br />Company: <br />Farnsworth Construction and Gravel <br />Company <br />Address: <br />ms;;' Q65- rn 1,75 I <br />Paonia, CO 81428 <br />Phone Number: <br />(970) 5274434 <br />Fax Number: <br />�o a-h"L. <br />Email Address:�`� <br />1, 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 />ture of Permittee. Corn rate Officer, Owner, or Documented Designee Date <br />NI -AF -01 <br />