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Page 5 of 5 <br /> Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have <br /> information on record). If this information is blank or not current,please type or print current contact information: <br /> Permittee Contact: Glenn Southwick <br /> Permittee Company: Glenn Southwick <br /> Address: 13800 Silver Springs Rd <br /> Jay Em, WY 82219 <br /> Phone Number: (307)334-2880 --1 _ 33 - Oq 1 I <br /> Fax Number: (307)334-2880 non <br /> Email Address: <br /> n ov1� <br /> Permitting Contact: Glenn Southwick <br /> Company: Glenn Southwick <br /> Address: 13800 Silver Springs Rd <br /> Jay Em, WY 82219 <br /> Phone Number: (307)334-2880 Ono - 'Z I - Z('1 3 <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: Glenn Southwick <br /> Company: Glenn Southwick <br /> Address: 13800 Silver Springs Rd <br /> Jay Em, WY 82219 <br /> Phone Number: (307)334-2880 2 <br /> a�O"' t s - Z(O-13 <br /> Fax Number: <br /> Email Address: <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 /> Signature of Permittee,Corporate Officer,Owner,or Documented Designee Date <br /> M-AF-01 <br />