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Page 5 of 5 <br />Division records indicate the following permittee/landowner 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 />Permittee Contact: Jack Clark Jr <br />Permittee Company: Jack Clark,Jr. <br />Address: P. O. Box 767 <br />Silverton,CO 81433 <br />Phone Number: 970)387-5243 <br />Fax Number: 970)387-5121 <br />Email Address: JClhardrock@aol.com <br />Permitting Contact: Charles R.Ponchak <br />Company: Charles R.Ponchak <br />Address: 15292 6050 Rd. <br />Montrose, CO 81401 <br />Phone Number: 970)249-2081 <br />Fax Number: 970)249-2081 <br />Email Address: <br />Inspection Contact: Jack Clark Jr <br />Company: Jack Clark Jr. <br />Address: P.O. Box 767 <br />Silverton, CO 81433 <br />Phone Number: 970)387-5243 <br />Fax Number: <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 with the Division approved mining and reclamation plans. <br />11-'17 <br />Sign of ermittee,Corporate O cer,Owner,or Documented Designee Date <br />M-AF-01