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• <br /> Page 5 of 5 <br /> Division records indicate the following permittee contact information. If this information is not current,please type or print <br /> current contact information: <br /> Permittee Contact: R.Lewis Fillmore Ron `;//mot e. <br /> Permittee Company: R.Lewis Fillmore �j /fes ale <br /> Address: P O Box 258 t 6C <br /> Boone,CO 81025 <br /> /gook/P Ct2 <br /> Phone Number: (719)568-6712 <br /> Fax Number: <br /> Email Address: Ronfill@hotmail.com <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 /> l <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />