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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman SL, 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 />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />—&— <br />SAF ETY <br />RECEIVED <br />Permit Information'Pttai <br />DEC 0 4 2015 <br />Permit Number: /1%-- 19 ?' - O 7 t2 <br />Divi§io,, or Reclamation,Operation Name: � Ca- �/� k nJ Mining & Safety <br />Permittee Information <br />Contact Person: -Ph u i p ae -E ,,� i 101 4 <br />i <br />Company Name: D G, <br />Street Address: L z S'' i4i-I- <br />City: F A el v`. <br />State: id e, W e, >S (1 G Zip: L( 0 I <br />Phone: ) G Si -- 2 /�3 9 <br />Email (optional): <br />641 <br />t1f2tZdat5 <br />Prospective Successor Information <br />Contact Person: <br />va-vbelf "for <br />Company Name: 1N( J t/U -- <br />Street Address:? P �C <br />City: Dr c MA/6 S Vet/O-GS <br />State: l Zip: Zj czo <br />Phone: ( C)3 ) ' 7c) <br />Email (optional): »'i eyim <br />Office of <br />Mined Land Reclamation <br />Inactive Mines <br />Denver • Grand Junction • Durango <br />Office of <br />Active and <br />