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Division zecords indicate the following permittee contact information. If this information is not current lease Page 5 <br /> current contact information: P type or print <br /> Permittee Contact: Andy R Norris <br /> Permittee Company: Jackson County <br /> Address: P.O.Box 488 <br /> Walden,CO 80480 <br /> Phone Number: (970)723-4481 <br /> Fax Number: (970)723-8437 <br /> ail 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 cond in accordance with the Division approved mining and reclamation plans. <br /> Signature of rmittee Corporate Officer Owner,or Documented Designee e Qn Date <br /> M-AF-04 <br />