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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: Dean Ormiston �Q �' l,� J6 <br /> Permittee Company: Baca County <br /> Address: 741 Main Street, Suite 1 <br /> Springfield,CO 81073 <br /> Phone Number: (719)529-3360 <br /> Fax Number: (719)523-6584 <br /> Email Address: Dormiston@bacacountyco.gov �/yd <br /> Permitting Contact: Dean Ormiston <br /> Company: Baca County <br /> Address: 741 Main Street, Suite 1 <br /> Springfield,CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: <br /> Email Address: Dormiston@bacacountyco.gov <br /> Inspection Contact: Dean Ormiston <br /> Company: Baca County <br /> Address: 741 Main Street, Suite 1 <br /> Springfield,CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: <br /> Email Address: Donmiston@bacacountyco.gov <br /> 1,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are <br /> being conducted i ccordance with the Division approved mining and reclamation plans. <br /> 22 <br /> Signatu of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> MA CI M-AF-04 <br />