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- - <br />Legal Identity Report U.S. Department of Labor /~~ <br />Mine Safety and Health Administration ` <br />"-.-rercrt.s re;,,,~•etl by law (30 C.F. R. 4t). Form Approved. OMB No. 44~Rt677 Expires Sep 7903 <br />rte to report can result in assessment of Nalat a •~o•e space is <br />~~i oe^.=~!y Kr•rnvingly making a false ~ gee. ~ea n air secbor• txbw. <br />s.alement can result in criminal prosecution Q Imt al Notice manse „sea seva~aie seer. <br />under § 110 0l the Federal Mine Safety and Dale <br />Health Act of 1977. ^ Change NOlioe <br />~~O ~n 7 I~g Day -Idaho ~ !a. 1481 _ <br />Fe~~de""rppa~ Mine Itlenlilication Number Mine Name <br />Zl~ysa faOC71t~ EO83 12~, H68pC148. O 82~ ~r$ P1'i'(S ~~~ <br />Mine Address City County Slate Zip Code <br />r <br />t:old/:'31yer John L. ~a:se32 ~ <br />Commodity Name of Operator Signature of Person Completing Form <br />Jong L. 3tavse3l, .;ine Euperia-~.eaceats 1131x8 Cotm~kr 3tsaci 12L,. Ht?aonxva, Colors@o 81326 <br />Person at Mine in Charge of Health and Safely <br />Name antl Title Adtlress <br />C,7~arlia ~lor, Base Cam :~aaalgrt, 43$8 Ca~niT Eoad 1~1+. Hesaerus. Colarmdo 81;26 <br />Person with Overall Responsibility fora Health and Safety Program at All of the Operators Mines, if the Operator is Not Directly <br />Involved in the Daily Operation of the Mine ~ ' <br />Name and <br />ress <br />rat Mine Identification Numbers of All Other Mines in which the Sole Proprietor, Partnership, Corporation, or Other <br />~nization Hasa 20°0 or Greater Ownership Interest <br />ID Numbers <br />Federal Mine Identification Numbers of All Other Mines in which Any Partner, Corporate Olticer, or Other Organization Official <br />Or Member Hasa 20 % or Greater Ownership Interest [not applicable to sole proprietorship] <br />ID Numbe? <br />Address of Recortl and Telephone Number [service of documents upon the operator will be completed by mailing the - <br />documents to this address) <br />Name Ttlle Telephone Number <br />Hastilton. H3a31toa, Ehaad 3e Ir1aT~aa A$#arn~_y(ty..21i7 ~9~ <br />Sireel Adtlress Ciry State Zip Code <br />Please Check the Appropriate Box and Complete the Applicable Section <br />^ I. Sole Proprietorship ^ II. Partnership ®III. Corporation ^ IV. Other <br />I. Sole Proprietorship <br />Trade Name Proprietor <br />up epee <br />