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Page 3a s <br />TDiv isicn twords irtd;cntc 11w m trernwion(Islam: fields indicate that we -do -not -1-save <br />information on record). If this information is blank or not current, please type or.pAnt chat contact mformatiox <br />Address: <br />MS. Cedar <br />Julesburg, CO 80737 <br />Phone Number: <br />(970) 474-3576 <br />Fax Number: <br />(970) 474-3558 <br />Email Address: <br />Scroadbridge@gmail.com <br />Permitting Contact: <br />Randy Renquist <br />ll <br />Company: <br />Sedgwick County <br />Address: <br />Phone Number: <br />223 S Cedar <br />Julesburg, CO 80737 <br />(970) 474-3576 <br />Fax Number:N9j,4=B�54_� <br />•y f1 , t'�,(� 3 (� rl <br />Email Address: <br />Inspection Contact: <br />Randy Renquist <br />�1/ V ( D <br />Company: <br />Sedgwick County <br />Address: <br />223 S Cedar <br />Julesburg, CO 80737 <br />Phone Number: <br />(970) 474-3576 <br />Fax Number: <br />Email Address:ka <br />t+G { ! G <br />1, the un rsigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />bein on ucted in accolhifbce with the Division approved mining and reclamation plans. <br />1 /% <br />of Permittee Cor orate Officer, Owner, or Documented Designee Date <br />N1 AF,4 <br />