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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 f�' 1 r��'��� C O L O RA D O <br /> p I V[ S 1 ON OF <br /> Denver,Colorado 80203 ((��� RECLAMATION <br /> Phone:(303)866-3567 �I y l MINING <br /> FAX:(303)832-8106 —&— <br /> SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS <br /> ?If,;-=CEIVED <br /> ADMINISTRATIVE INFORMATION <br /> DEC 2016 <br /> Permit Information of Recfamatiott, <br /> Permit Number: M l (�Cl Mining&Safety <br /> Operation Name: 4) �,� ��i�llf� <br /> Permittee Information M+ .tiVl�kit'P,d— <br /> Contact Person: A <br /> Company Name: Tlj N <br /> Street Address: G j,�,_c/ e- goo. <br /> City: /10 cl C .fit C, Mal <br /> State: Zip: <br /> Phone: <br /> Email(optional): <br /> Prospective Successor Information / <br /> Contact Person: A41ji..l <br /> Company Name: 1&'C'e �1 o u n! fY S�v /✓ <br /> Street Address: /�0 /3 O u f <br /> City: /uyo ,V S <br /> State: ,0 p Zip: <br /> Phone: ( -3 03) 2- <br /> Email (optional): <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />