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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 /> Permittee Contact: Laurens W.Leffmgwell,Jr. - <br /> Permittee Company: Gold Basin Mine,LLC,c/o — <br /> Simpson Estates <br /> Address: 30 N.La Salle St., Ste 1232 <br /> Chicago,IL 60602 <br /> Phone Number: (312)726-3110 <br /> Fax Number. <br /> Email Address: Jon@simpsonestates.com <br /> I,the undersigned,hereby state that the information provided in this eport is true and accurate,and that site operations are <br /> bein7conduc in accordance with the Div' o� pproved minin d reclamation plans. <br /> f <br /> �.. Z3 o(4 <br /> gnat re o erm ttee C c ier or Documented Designee Date <br /> r <br /> / M-AF 2 / / <br />