Laserfiche WebLink
' ,i <br />II <br />C~ <br /> <br />-Z- <br />ADMINISTRATIVE INFORMATION: <br />1. Permit Number: <br />2. Operation Name: <br />3. Current Permitted Operator: <br />Contact Person: <br />Company Name: <br />Street: <br />City: <br />State: <br />Area Code: <br />4. Successor Operator: <br />Contact Person: <br />Company Name: <br />Street: <br />City: <br />State: <br />Area Code: <br />IRS Tax ID No. <br />5. Application Fee <br />t-~z/ ~-.097 <br />7~i~JP ~3 G-RAVeI ~~T <br />m~cNA~'L ~u~xEfr <br />}~0 ~ox oZ4~ <br />~/}~ F-< i LL A 't'A ~ <br />n/El+i /n~1(14D Zip Code: 88oy7 <br />,.~n'S Telephone: ~~y -yy$ <br />~n ~ W e> ~ LO JC'~~ <br />(9 ^i'iAY C'~ctr~TY <br />'moo ':3o~C y~G <br />rh ~c~lG~.7A}' <br />Cole~N~_ Zip Code: <br />C/7(~ Telephone: ~o~(e - .~~~%f <br />or Social Security No.: ~y- i;06o79i <br />$100.00 <br />Make check payable to the Division of Minerals and Geology <br />R.F. l--acs-~~ <br />Nod . 1- <br />qH-N l <br />