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p2op4 nc <br /> ]]iuir.nn ra.-11rAm indirttha r r,.,;ttee" risenrmnYinn Nani,fiPlAa 31ncrr_utta 1y,t iv _1147% dna <br /> information on record). If this information is blank or not current,please type or print cutreet contact inkirmt®iam <br /> 1 11rtmillsttaaiirt iltekamiNow <br /> linadkItaNdLIED <br /> Address: P.O. Box 5356 <br /> Pagosa Springs, CO 81147 <br /> Phone Number: (970)946-3074 <br /> Fax Number: 479)364-66--- <br /> Email Address: 4attgost directwret-5 kV'awc,fAc p�,,a_t ( , co <br /> Permitting Contact: Timothy M. Scanlon (� <br /> Company: TMS Consulting <br /> Address: P.O. Box 53 <br /> Saguache, CO 81149 <br /> Phone Number: (719)655-2709 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Roger August <br /> Company: Mask Ranch, LLC <br /> Address: P.O. Box 5356 <br /> Pagosa Springs, CO 81147 <br /> Phone Number: (970)946-3074 <br /> Fax Number: <br /> Email Address: ,l gqast®di-e,st net VUa f<1-awL� o v�Ai I <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 approv-d mining and reclamation plans. <br /> g4.5,riAgegke, i3 ' � //7/7// 7 <br /> ture ofermittee,Corporate Officewner, h Documented esi2nee Da <br /> M-AF-01 <br />