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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 DIVISION <br /> O L E RA D O <br /> Denver,Colorado 80203 D I V I S I O N O P <br /> Phone:(303)8663567 RF MIII N NGON <br /> FAX:(303)832-8106 —&— <br /> SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS <br /> ADMINISTRATIVE INFORMATION <br /> Permit Information <br /> Permit Number. M12644-1-M— 1 tZ o[( —d31 <br /> Operation Name: 0-0[tr+'-16 �Ac65 Zocl <br /> Permittee Information <br /> Contact Person: Kim Barickman <br /> company Name: Colorado Moss Rock, Inc. <br /> Street Address: PO Box 51 <br /> city: Rye <br /> State: Colorado Zip. 81069 <br /> Phone: (719 )248-7333 <br /> Email(optional): <br /> Prospective Successor Information <br /> contact pemn: Nick Simpson <br /> Company Name: 17'Premier Moss Rock LLC <br /> Street Address: 5120 Windsor Avenue <br /> city: Edina <br /> State: MN Zip: 55436 <br /> Phone: (612 ) 237-2968 <br /> Email(optional): njsimpson0l@gmail.com <br /> Office of Office of <br /> Active and <br /> Mitred Land Reclamation Denver•Grand Junction•Durango <br /> Inactive Mines <br />