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STATE OF COLORADO <br /> DIVISION OF RECLAMATION, MINING AND SAFETY CEIV ") <br /> Department of Natural Resources <br /> 1313 Sherman St.,Room 215 z9zz n Iry I SOI COLOR <br /> N of <br /> Denver,Colorado 80203 MAR 10 RECLAMATION <br /> Phone:(303)866-3567 r MATION, MINING <br /> FAX:(303)832-8106 DIVISION S RECLAMATION, _ _ <br /> IJIINING &SAFETY PJIINER LS SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS <br /> ADMINISTRATIVE INFORMATION <br /> Permit Information <br /> Permit Number: M 0 4 <br /> Operation Name: Mt <br /> Permittee Information <br /> Contact Person: I)JOwtZ!p� i <br /> Company Name: SthI✓ <br /> Street Addre s: j cz Pn'ty—M,1; A 4,t �A Aw,,* 3 <br /> City: <br /> State: Z / 7 <br /> Phone: ( `� G�) ��Gf — 3�j O <br /> Email (optional): <br /> Prospective Successor Information <br /> Contact Person: <br /> Company Name: 1.Vi , <br /> Street Address: , <br /> City: PAR b 4 <br /> State: �& Zip: <br /> Phone: ( 7/9 ) "27 S— — <br /> Email (optional): It Aid l _ G !04 Ph no • �Q�j <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />