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Division records indic.ttc the hollowing perntinec/landowner contact information(blank fields indicate tPage have <br /> m <br /> inibrati(ml on record'. 11,11,is inliirnntttion is blank or not curren hat we d <br /> t,please type or print current contact infortn<ttion: <br /> t <br /> :k K - <br /> Perntiftee company: y _ - <br /> t <br /> Address: <br /> uT <br /> Phone Number: <br /> (z� lLi '; .c- ,aKC° e4w toF (= � cc", tv4,.�.. <br /> Permitting('ontacl: <br /> _ - <br /> ontpany: <br /> Address: _ <br /> Phone Number: <br /> FaxNumher: <br /> !,mail Address: _ <br /> (inspection Contact: _ <br /> Company <br /> Address: <br /> Phone Number: <br /> Fax Number: <br /> Finail Address: <br /> I,the undersigned, here>y s-atc that the information provided in this report is true and accurate,and that site operations are <br /> being conducted in accc R anee with the Division approved mining and reclamation plans. <br /> gnat tire of Permtttee,I-tt;rporate Officer,Owner,or Documented Desiener <br /> M NF-of Date <br />