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Q N G 6tw J 1 i-1 1 L' V1' <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources L <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: M- 1992 -045 <br />Operation Name: Gold Basin Mine <br />Permittee Information <br />Contact Person: James Van Ella <br />Company Name: N/A <br />Street Address: 180 LN 200 Bass Lake <br />City: Angola <br />State: I N Zip: 46703 <br />Phone: ( 260 ) 665 -7060 <br />Email (optional): <br />Prospective Successor Information <br />Contact Person: Laurens Leffingweil <br />Company Name: Gold Basin Mine, LLC <br />Street Address: c/o Simpson Estates, Inc., 30 N. La Salle St., Ste. 1232 <br />City: Chicago <br />State: I L Zip: 60602 <br />COLORADO <br />DIVISION O F <br />RECLAMATION <br />MINING <br />SAFETY <br />RECEIVr"- <br />DEC 10 2013 <br />Dlvlsion of Reclan oLion, <br />Mining & Safety <br />Phone: ( 312 ) 726 -3110 <br />Email (optional): Jon @simpsonestates.com <br />v� <br />Office of Office of }� <br />Mined Land Reclamation Denver - Grand Junction - Durango Active and <br />Inactive Mines <br />