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Division records indicate the following permittee contact information. If this information is not current, please type or <br />print current contact information: <br />Permittee Contact: <br />Permittee Company: <br />Address: <br />Phone Number: <br />Fax Number: <br />Email Address: <br />I, the undersigned, hereby s that the information provided in this report is true and accurate, and that site operations <br />are being conducted in ac rdance with the Division approved mining and reclamation plans. <br />of Corporate Officer, Owner, or Documented Designee <br />Date <br />