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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 j C. 1� 6 U f -e—k <br /> Permittee Company: Baca County �� C 7 C C w <br /> Address: 741 Main St.,Suite 1 <br /> Springfield,CO 81073 <br /> Phone Number: (719) 529-3360 ( !� q � �� 3 3 <br /> Fax Number: (719)523-6584 <br /> Email Address: Dormiston@bacacountyco.gov 6 t 1^t;' 64,,� co col -y G-0 S 0 <br /> Permitting Contact: Charles Wait <br /> Company: Baca County <br /> Address: 741 Main St., Suite l <br /> Springfield,CO 81073 <br /> Phone Number: (719)523-6532 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Charles Wait <br /> Company: Baca County <br /> Address: 741 Main St.,Suite 1 <br /> Springfield,CO 81073 <br /> Phone Number: (719)523-6532 <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 a proved mining and reclamation plans. <br /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> �� r I M-AF-04 <br />