2017-12-07_REPORT - M1992045

• Permit No: M1992045
• IBM Index Class Name: REPORT
• Doc Date: 12/7/2017
• Doc Name: Annual Fee/Report/Map
• From: Gold Basin Mine, LLC, c/o Simpson Estates
• To: DRMS
• Annual Report Year: 2017
• Email Name: DMC
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have
information on record). If this information is blank or not current,please type or print current contact information:
Permittee Contact: Laurens W.Leffingwell,Jr.
Permittee Company: Gold Basin Mine, LLC,do
Simpson Estates
Address: 30 N.La Salle St., Ste 1232
Chicago,IL 60602
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Permitting Contact: Laurens Leffingwell
Company: Gold Basin Mine, LLC,do
Simpson Estates
Address: 30 N.La Salle St., Ste 1232
Chicago,IL 60602
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
Inspection Contact: Laurens Leffingwell
Company: Gold Basin Mine,LLC,do
Simpson Estates
Address: 30 N.La Salle St., Ste 1232
Chicago,IL 60602
Phone Number: [phone]
Fax Number:
Email Address: [e-mail]
I,the und- .1_ ed,here•`,ltate that the information provided in this report is true and accurate,and that site operations are
being co d , -d in a7'rdance with the Division approved 'i ing and reclamation plans.
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Signatu of rI,itt- C, ,,'r 111;, - w er,or ' i m nti. '-:i.,.ee D to
M-AF-02