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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 <br />print current contact information. <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 <br />of A I <br />31/ r <br />Owner. or Documented Designee Date <br />