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ljo MZDILIaL�� <br /> Page 5 of 5 <br /> Division records indicate the following permittee/landow er 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: <br /> Permittee Cornpmy: <br /> 1.2 <br /> Address: <br /> Phone Number: <br /> Fax Number: <br /> Email Address: <br /> Permitting Contact: <br /> Company: <br /> Address: <br /> Phone Number: <br /> Fax Number: <br /> Email Address: <br /> Inspection Contact: <br /> Company: <br /> Address: <br /> Phone Number: <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 con ted in accordance with the Division approved mining and reclamation plans. <br /> I I- /3 'Z01-7 <br /> Siinature of Permittee.Corporate Officer,Owner,or Documented D '�e Date <br /> M-AF-01 <br /> PEW CR.due_date <br /> n <br />