MINE COMPANY NAME:                                 
MINE NAME:

Statement: I, , an authorized representative of declare that only the items listed on this and all consecutively numbered Index Sheets are intended as revisions to the current permit document. In the event that other changes inadvertently occurred due to this revision, those unintentional alterations will not be considered approved.

NOTES:
1) Include all revision or change elements and a brief description of or reason for each revision element.
2) List all revision or change elements in sequence by volume number; number index sheets sequentially as needed.