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i <br /> y <br /> 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: Mark Dorenkemp <br /> Permittee Company: Prowers County <br /> Address: 109 E. Sherman St. <br /> Lamar,CO 81052 <br /> Phone Number: (719)336-5536 <br /> Fax Number: (719)336-9633 <br /> Email Address: <br /> Permitting Contact: Tony Garcia <br /> Company: Prowers County <br /> Address: 109 E. Sherman St. <br /> Lamar,CO 81052 <br /> Phone Number: (719)336-6631 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Tony Garcia <br /> Company: Prowers County <br /> Address: 109 E. Sherman St. <br /> Lamar,CO 81052 <br /> Phone Number: (719)336-6631 <br /> Fax Number: <br /> Email Address: <br /> I,the undersigned,hereby state that the information rovided in this report is true and accurate,and that site operations are <br /> ban conc4ucted}n��ordance with theDivision roved mining and reclamation plans. <br /> (A/J 4� A-. ,.�ature of Permittee,CoC pof orate Officer,Owner,or Documented Designee Date <br /> M-AF-04 <br />