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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: Tressesa Martinez <br /> Permittee Company: Conejos County <br /> Address: P.O. Box 157 <br /> 6683 County Rd 13 <br /> Conejos, CO 81129 <br /> Phone Number: (719)376-5772 <br /> Fax Number: (719)376-5661 <br /> Email Address: Tressesa@co.conejos.co.us <br /> Permitting Contact: i e <br /> t ✓1 Q r•�/n e <br /> Company: Conejos County <br /> Address: P.O. Box 157 <br /> 6683 County Rd 13 <br /> Conejos, CO 81129 <br /> Phone Number: (719)376-5772 <br /> Fax Number: (719)376-5661 <br /> Email Address: �' . o.us <br /> urJ,i✓I eZ CO• 6yiesys.C'o <br /> Inspection Contact: NtH el // <br /> Company: Conejos County <br /> Address: P.O. Box 157 <br /> 6683 County Rd 13 <br /> Conejos, CO 81129 <br /> Phone Number: (719)376-5772 <br /> Fax Number: (719)376-5661 <br /> Email Address: P-hi e os.co.us <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 Of r,Owner,or Documented Designee Date <br /> M-AF-04 <br />