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() o d (w <br /> c µ STATE OF COLORADO <br /> DIVISION OF RECLAMATION,MINING AND SAFETY <br /> Department of Natural Resources <br /> 1313 Sherman St.,Room 215 10 f0 iv i lk k 0 o- <br /> Denver,Colorado 80203 O/� l RC�.t AA1:1TI€)iv <br /> Phone:(303)866-3567 5 J11 I N ING <br /> FAX:(303)832-8106 <br /> SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS l/U <br /> RECEIVED <br /> ADMINISTRATIVE INFORMATION MAY 2 6 2017 <br /> of Rmlarnaam <br /> Permit Information Wong SA* <br /> Permit Number: M _ Z 0 D 0 O <br /> Operation Name: c� r fl �o Qd G-r-a Vey Pi <br /> Permittee Information <br /> Contact Person: moose_ pp toe" <br /> Company Name: <br /> Street Address: a a 4 b L—n-t 2 A V ey i,{-,,_0 <br /> City: P LA _e_'6 I d <br /> State: y 10 ro(C). Zip: I �0 <br /> Phone: (119 ) S 61 — g O S q <br /> Email(optional): <br /> Prospective Successor Information <br /> Contact Person: ]R I G k a r A <br /> Company Name: 2 5 i Q ),C2 r� <br /> 1 <br /> Street Address: oZ b 6 yf'n u R /.,v 4 <br /> City: A'4 e% I U <br /> State: C_.n 12 d. 6) Zip: g I U 't nl D <br /> Phone: ( -7 1 q ) S ,6 90 S y <br /> Email(optional): K r n f' r -1 o�) /-n i n C�1 S�' ( n , co 141 <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />