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h ,g_oz$- <br />STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY Department of Natural Resources so <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />APPLICATION FORM <br />FOR TRANSFER OF MINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />ADMINISTRATIVE INFORMATION <br />Permit Information <br />Permit Number: M1990 -025 <br />Operation Name: Hay Camp Pit <br />Permittee Information <br />Contact Person: Casey_ McClellan, Owner <br />Company Name: Ivil <br />Street Address: P O Box 1525 200 4th Street <br />City: Dolores <br />State: Colorado <br />Zip: 81323 <br />Phone: J70 ) 882 -7878 <br />Email (optional): caseymcclellan(.msn.com <br />Prospective Successor Information <br />Contact Person: Dean Roundtree, Superintendent <br />Company Name: Montezuma County (Road Department) <br />Street Address: 109 West Main Street <br />CO:,4*1 ORAD <br />D I v I S t O N RECLAMATIO <br />MINING <br />SAFETY <br />RECEIVE <br />3EP 13 20i "i <br />DIASION OF DECLAMATION <br />MINIWAMD SAFETY <br />city: Cortez <br />State: Colorado Zip: 81321 <br />Phone: 1970 )565 -8666 <br />Email (optional): droundtree @co.montezuma.co.us I/ ' <br />///^��� 14 © • J V <br />&J�t y 5 ZZ�Z,D <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and <br />Inactive Mines <br />