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Permittee Company: Kit Carson County <br /> Address: P.O. Box 160 <br /> Burlington, CO 80807 <br /> Phone Number: (719)346-8139 <br /> Fax Number: (719)346-7242 <br /> Email Address: <br /> Permitting Contact: Randy Schafer <br /> Company: Randy Schafer <br /> Address: 40586 Co. Rd. 21 <br /> Haxtun, CO 80731 <br /> Phone Number: (970)854-3778 <br /> Fax Number: (970)854-3811 <br /> Email Address: <br /> Inspection Contact: 'malt 66wamt <br /> b <br /> Company: Kit Carson County <br /> Address: Road&Bridge Supervisor <br /> P.O. Box 160 <br /> Burlington, CO 80807-0160 <br /> Phone Number: (719)349-1985 <br /> Fax Number: (719)349-7242 <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 /> Signature of Permittee,Corporate Officer, caner,or Documented Designee Date <br /> M-AF-04 <br />