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STATE OF COLORADO <br /> DIVISION OF RECLAMATION,MINING AND SAFETY <br /> Department of Natural Resources <br /> 1313 Sherman St.,Room 215 C O L O RA D O <br /> D I V S I O N O F <br /> I <br /> Denver,Colorado 80203 RECLAMATION <br /> Phone (303)866-3567 MINING <br /> FAX.(303)832-8106 _&— <br /> SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS'' <br /> ADMINISTRATIVE INFORMATION <br /> Permit Information <br /> Permit Number: <br /> Operation Name: ' 11 ( k2eIc ' �a _,16 ,C <br /> Permittee Information �— <br /> Contact Person: 'r:M � <br /> Company Name: G <br /> Street Address: x 7 <br /> City: l ►�q <br /> State: 0/D Zip: 12- f <br /> Phone: ("7( r ) S9 — 2 7 3G <br /> Email (optional): <br /> Prospective Successor Information <br /> Contact Person: ``7ur)� z�LGL <br /> Company Name: )Z�tAtt- 'Aoat I6 M it)I <br /> Street Address: rj� �J <br /> City: 't`rQ 'C'YI� <br /> State: ft Zip. �Z 3 3 RECEIVE® <br /> � <br /> Phone: (��� ) Ya- [.f�� 7 FEB 0 5 2014 <br /> � ) / Division of Reclamation, <br /> Email (optional): ��T ?�IbI/Q�7'l'�"S �� , COIF. Mining&Safety <br /> Office of l Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango L� ct a� <br /> Inactive Mines `'G", <br /> L✓X ro <br />