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Legal Iden'~ty Report <br />• U.S. Department of La~ <br />Mme Safety and Health Administration <br />-~ - ~epcn s reG~_azd by law 130 C F.fl. 4t) <br />e to report can result in assessment of <br />penally Knovnngly making a false <br />_.a.zment can rzwh in criminal prosec~lion <br />under 4 t t 0 of thz Federal Mine Safety and <br />Health Act of 1977 _ <br />'al Mine Itlen Utic ation Number <br />Fort Approvztl. O'd (3 No .4~R' 67- Expue<. <br />Nob. ample space is <br />r'-{ _ ,..~ ~n any sectmn cebw. <br />l-} hi liar Pldllce = se a seoa,ab sneer <br />D3te2p <br />^ Chanye Nohce <br />~j <br />''-D t 983 <br />tf~ COnntp Hoed 1211. T;es'oexelt3. Colmedo S1R25 (La Playa Comity) <br />l.t.re Address City Counry State Zip Code <br />r <br />~~~~ )...... <br />"~'~ :. ?S Jong 3a. 1~i33'3i~ ~ ~ i' <br />Commotlny Name cr Operator Signature of Person Completing Form <br />Jdm I.. ':usell, :line ~unerin+.etyden~ !+3lc8 Can:a':r r~oao 326, ieaoex~s~ Colarsdo 8136 <br />Person al Mine in Charge of Health and Safely <br />Name and Title Atltlress <br />Gh2slia '%T,+lar, tease Caa~ :•laaatRer, I;3a3 Comity .°.oad l~L, Hesnexvs. Cola~ado 813_?6 <br />Person with Overall Responsibility for a Health and Safety Program al All of the Operator's Mines, if the Operator is Not Directly <br />Involved in the Daily Operation of the Mine <br />Hz^:e and Tioz <br />~ral Mine Idenliflcation Numbers of All Other Mines in which the Sola Proprietor, Partnership, Corporation, or Other <br />nization Hasa 20°6 or Greater Ownership Interest <br />ID N~mbzrs <br />Federal Mine Identilicalion Numbers of All Other Mines in which Any Partner, Corporate Olfiear, or Other Organixalion Official <br />Or Member Hasa 20 % or Greater Ownership Interest [nor applicable to sole proprietorship] <br />ID Numbers <br />Address of Record and Telephone Number [service of documents upon the operator will be completed by mailing the <br />documents to this address] <br />Name Title Telephone Number <br />~-dlttxii, o.,,,,+TtCtn. fttand ,.o'`aTat~a^n g i~a,;tenvv ?03...?It7 '~T <br />Streit Atltlress Cdy State Zip Code <br />Please Checx file Appropri <br />' ~ 1. SOIe Prdpne(Orship <br />I. Sole Proprietorship <br />TreA P:ame <br />Boz and Complete the A <br />II. Partnership <br />secuon <br />© III. Corporation ~ IV. Other <br />P~oooetor's Andress (streep City Zip Code <br />