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Pase5 DEC <br /> Division records indicate the following ermitteeflandowner contact information(blank fields indicate that we do not <br /> information on record). If this infoxmafion is blank or not current,please type or print anrunat contact info mariiaa: <br /> LELlienew nacnr1 .1 p X1,5 <br /> Teuia - Itk.ta <br /> Address: _ 'r O.Bou lli <br /> Kiowa,CO 80117 <br /> Phone Number: (303)621-3157 2 ? G' / 31529 <br /> Fax Number: (303)621-3159 `7 <br /> Email Address: wan c VL(;(n,s QJPlbQo4Ir[y-(O-s172 <br /> Permitting Contact: Amannpv'$1 ]j'I „ <br /> Company: Elbert County Road and Bridge. II <br /> Address: 218 Cheyenne Street <br /> P.O.Box 116 <br /> Kiowa,CO 80117 <br /> Phone Number: (303)621-3157 <br /> Fax Number: (303)621-3159 <br /> Email Address: <br /> Inspection Contact: 1 r 4 � r ct I� j VAS <br /> Company: Elbert County Road and Bridge j� <br /> Address: 218 Cheyenne Street <br /> P.O. Box 116 <br /> Kiowa, CO 80117 <br /> Phone Number: (303)621-3157 <br /> Fax Number: (303)621-3159 <br /> Email Address: <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 ith the Division approved mining and reclamation plans. <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />