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Page 5 of 5 <br />Division records indicate the following permittee/landowner contact information (blank fields indicate that we do of have <br />information on record). If this information is blank or not current, please type or print current contact information, <br />-o-- -------, ---- L=1UL LtlV; ,Lluvrumauon 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 />✓ �' —� <br />Signature of Permittee Car orate Officer, Ownerm <br />, or Docuented Designee <br />NI AF -01 --- Date <br />