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STATE OF COLORADO <br /> DIVISION OF RECLAMATION, MINING AND SAFETY RECEIVED <br /> Department of Natural Resources <br /> APR 172025 COLORADO <br /> Sherman1313 St.,Room 215 DIVISION OF <br /> Denver,Colorado 80203 RECLAMATION <br /> Phone:(303)866-3567 MINING <br /> FAX:(303)832-8106 Colorado Division of Reclamation, <br /> Mining and Saftey SAFETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS <br /> ADMINISTRATIVE INFORMATION SO-4 <br /> IiR1/ZTT <br /> Permit Information <br /> Permit Number: - I'r I --! a I <br /> Operation Name: 1-I 41. P r fi aka Lci r t 's P,4 <br /> Permittee Information ff <br /> Contact Person: CI CC, LC�tO <br /> Company Name: A "J4l}[, (j rl L <br /> Street Address: Pt) R o ?s Ci 10 <br /> City: CPIO CO AO .) (i'rn S <br /> State: Colo rot Ao Zip: O q0000 <br /> Phone: ( ) L C a al 1 5 3 3 <br /> Email (optional): d,e C64-6) VAG ," I CO m <br /> Prospective SuccessorlIAA Information ((�� <br /> Contact Person: Crla A. is et c\ S0, Iq V► ' i /er <br /> Company Name: <br /> Street Address: / a a G 5 I3, Cypress f i Ye <br /> City: Pey1oviCypress <br /> State: Co 0 (a d a Zip: cce) I <br /> Phone: (7/ _( 6 - 5 [ 56' <br /> Email(optional): yY1 y i� T rtSti;✓te.�c va !'t©o.t'OM <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />