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STATE OEgQLORADO <br /> DIVISION OF RECLAMATION, MINING AND SAFETY ^ <br /> Department of Natural Resources �,1 <br /> p,i� COLORADO <br /> 1313 Sherman St.,Room 215 �! 1�� 1 D I v 1 s 1 o N o f <br /> Denver,Colorado 80203 � RECLAMATION <br /> Phone:(303)866-3567 �0� MINING <br /> FAX:(303)832-8106 SO01 —&— <br /> SAF ETY <br /> APPLICATION FORM y nJG�n�FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS RECEIVED <br /> SEP 12 2016 <br /> ADMINISTRATIVE INFORMATION <br /> of Pedamation, <br /> Moing&Safety <br /> Permit Information <br /> Permit Number: �J l <br /> RECOWD <br /> Operation Name: <br /> Permittee Information <br /> �Iicryry/n� l I Divismeici of R wabon, <br /> Contact Person: Da,6tf-.[ <br /> Company Name: <br /> Street Address: q 0 ( � <br /> City: A I a <br /> State: �� Zip: <br /> Phone:A j ) <br /> 55q- 3('/3o <br /> Email (optional): <br /> Prospective Successor Information <br /> Contact Person: <br /> =W- <br /> Company Name: J C <br /> Street ddress: � �-� �1��I <br /> o e <br /> City: <br /> State: Zip: <br /> Phone: (4 ( 9 ) 5r,"n — 169 H <br /> Email (optional): 17 �,� �—V—) �0 kc r C W-1 <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />