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Page 5 of 5 <br />Division records indicate the following permittee contact information. If this information is not current, please type or <br />print current contact information: <br />Permittee Contact: <br />,a^ i _ / „ d n S1—erz 'T`_ J�► �- <br />Permittee Company: <br />e a <br />� I / Co. . C, <br />Address: <br />150 61VILWOM <br />S of 6 ,,, , J <br />Phone Number: <br />Fax Number: <br />Email Address: <br />" <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 />WAF-01 (/ 40tjo(�100, W <br />Owner, or Documented Desisnee <br />!N3 -1S - <br />Date -1S- <br />Date <br />