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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 print <br />current contact information: <br />Pennittee Contact: <br />Laurens W. Leffingwell, Jr. <br />Permittee Company: <br />Gold Basin Mine, LLC, c/o <br />Simpson Estates <br />Address: <br />30 N. La Salle St., Ste 1232 <br />Chicago, IL 60602 <br />Phone Number: <br />(312) 726-3110 <br />Fax Number: <br />Email Address: <br />Jon@simpsonestates.com <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. .roved mining and reclamation plans. <br />i <br />Sign <br />M -AF -02 <br />re Permittee C <br />4l/ <br />.t _d r,, <br />ocumented Designee <br />to <br />