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P,A,W <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866-3567 <br />FAX: (303) 832-8106 <br />STATE OF COLORADO <br />APPLICATION FORM <br />FOR TRANSFER OF MINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />ADMINISTRATIVE INFORMATION <br />Permit Information <br />Permit Number: M `W - O 1 Z <br />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />SAFETY <br />RECEIVED <br />�� <br />SEP 14 2015" <br />Operation Name: LEE No Z. PIACEP� UM W <br />- <br />Permittee Information <br />Contact Person: jSccIANLF- ' CONWW, <br />Crete Name: J-TA.i LEL J C QN NER <br />Street Address: Zea 5: (fkeye1cSa1'7 -2 ' <br />City:/.rzo51- <br />State: (--0L0 Zip: 50W <br />Phone: -'30,3 )= - q03 <br />Email (optional): <br />Prospective Successor Information <br />Contact Person: I koMbS MUSGN 1 VALFARZIF, MUSCia <br />Gempa*y Name: <br />/S L z(E M <br />i <br />Street Address: 514- AMEp-IC6S WWI 3� <br />City: BOX EmER, <br />State: S D <br />Phone: (WO )0^51201 <br />Zip: 51111 <br />Email (optional): VIS US(3A J ROCIT( MOIL. LONA <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and <br />Inactive Mines <br />