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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />t� Sd-01 p)l� bh I <br />�C4f <br />f a$21071- <br />STATE OF COLORADO <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX (303) 832 -8106 <br />f D -oj- <br />APPLICATION FORM <br />FOR TRANSFER OF NIINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />ADNIINISTRATIVE INFORMATION <br />Permit Information <br />L/ Permit Number. I// - &6 - `0 <br />Operation Name: 12 (2 r e- -�P- 1< <br />Permittee Information <br />Contact Person: M )G[4 yj-&- ( f l ooy e <br />Company Name: m i /U ( A) q (?o rA e A W -,/ <br />Street Address: oq 77 q 5- A) S �' (�c� • , � <br />City: /!%adn- <br />State: (-®. zip: <br />Phone: _ ( �76 ) 864 - 7 61 Y <br />Email (optional): V100-Mike 0 40L. C'OM <br />Prospective Successor Information <br />Contact Person: <br />i rte' al !�E? <br />41:` p:state• Zi <br />Phone: (" ) ZQ p 2-4 3::;L <br />Email (optional): <br />rej <br />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />SAFETY <br />RECEIVED <br />�NGo M P�7� <br />APR 02 2015 <br />Division of RecMmation, <br />Muting & Safety <br />GflW4d? y50 <br />1106, <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and <br />Inactive Mines <br />