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Page 5 ors <br />Division records indicate the following permittcellandowner contact information {blank ficlds indicate that we do not have <br />information on record►. If this information is blank or not current, please type or print current contact mfonnation <br />Permittee Contact: <br />Adam Schultejattn <br />Permittee Company: <br />120 85 LLC <br />Address: <br />10925 East 120th Avenue <br />Iienderson, CO 80640 <br />(303) 669-3623w <br />Phone Number: <br />Fax Number: <br />Email Address: <br />Adamds.asoa gmaO.com <br />Permitting Contact: <br />Adam Schultejann <br />Company! <br />120 85 LLC <br />Address: <br />10925 E. 120th Ave <br />HendcOan, CO 80640 <br />Phone Number: <br />Fax Number: <br />Dnr dmisminadminCustute.co.us <br />-- <br />Email Address: <br />inspection Contact: <br />Adam Schultcjann <br />Company: <br />120 85 LLC <br />Address: <br />10935 E. 120th Ave <br />Henderson, CO 80640 <br />Phone Number. <br />Fax Number; <br />Email Address: <br />Dnr—drrm-;minadmin(cc,;tatc.co.us <br />I, the undersigned, hereby state that the mfmmation provided in this report is true and accurate, and that site operations are <br />being conducted in accordance with the Division upproved mining and reclamation pians. <br />tll3l � � <br />. nature or Pir-itipy, Forygrole OWE, r, r, or Documented Designee Date <br />. Arm <br />