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Page 5 of 3 <br />-Division records indicate the Following permitteellandowner 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 />IrermrtteeCoU <br />Tom-Bruffiffim <br />Permittee Company- <br />Inc. <br />Address: <br />9296 Windhaven Dr. <br />Parker, CO 81034 <br />Phone Number: <br />(719) 469-0840 <br />Fax Number: <br />Email Address: <br />Tom.brubaker@valco-inc.com <br />Permitting Contact: <br />raeerge Gott@ <br />r <br />CompaW- <br />Address: <br />d. <br />Phone Number: <br />- <br />Fax Number: <br />Email Address: <br />Inspection Contact: <br />—Gvt O rut oke <br />Company: <br />n <br />V CL ( CO. k G <br />Address: <br />P , r. R -1 <br />"v e" 1V <br />�c,�.r �✓ Ca � o r 3� <br />Phone Number: <br />— - <br />7( — `e6 g' 66 44 0 <br />Fax Number: <br />ff OrT37-T652 <br />Email Address: <br />L <br />T eVA- .1.0 V. ✓�. Com. �c f✓ dw> I/c,"( G D <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. Corporate Officer, Owner, or Documented_ Designee Date <br />St AF - J <br />