2015-02-02_REVISION - M1992045

• Permit No: M1992045
• IBM Index Class Name: Revision
• Doc Date: 2/2/2015
• Doc Name: Application CN01
• From: Gold Basin, LLC
• To: DRMS
• Type & Sequence: CN1
• Email Name: DMC
• Email Name: GRM
• Media Type: D
• Archive: No

-3-
13. Correspondence Information:
APPLICANT/OPERATOR (name,address,and phone of name to be used on permit)
Individual's Name: Laurens Leffingwell Title:Member
Company Name: Gold Basin Mine
Street/P.O.Box: 1700 Wadsworth Road P.O.Box:
City: Old Mill Creek
State: Illinois Zip Code. 60083
Area Code: (847 ) Telephone: [phone]
Fax Number: ( ) Telephone:
PERMITTING CONTACT (if different from applicantloperator above)
Individual's Name: George M.L. Robinson Title:Principal
Company Name: R Squared, Inc
Street/P.O.Box: 3926 North State Hwy 67 1?O.Box:
City: Sedalia
State: CO Zip Code: 80135
Area Code: (303 ) Telephone: [phone]
Fax Number. ( ) Telephone:
INSPECTION CONTACT
Individual's Name: See Permitting Contact Title:
Company Name:
Street/P.O.Box: P.O.Box:
City:
State: Zip Code:
Area Code: ( ) Telephone:
Fax Number: ( ) Telephone:
CC: STATE OR FEDERAL LANDOWNER(if any)
Agency: Not Applicable
Street:
City:
State: Zip Code:
Area Code: ( ) Telephone:
CC: STATE OR FEDERAL LANDOWNER(if anv)
Agana. Not Applicable
Street:
City:
State: Zip Code:
Area Code: ( ) Telephone: