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. STATE OF COLORADO <br />O1Y1510N OF MINERALS AND GEOLOGY <br />Department of Natural Resources <br />RECEIVE® <br />~OF'CO[O' <br /> ~ O <br /> <br />1313 Sherman St.. Room 21 S <br />Denver, CO 80203 <br />qq <br />, , , JU L O 3 2OUG w' <br />, <br />'L <br />•' a i~•r <br />Phone: f30h d66-35ti T. -- <br />FAX: 13031 P33-N 106 ~ ~Ivlsipp Of MlpefalS Bpd GQpIOyy Roy Romer <br /> Governor <br /> <br />TRANSFER OF <br />PERMIT AND SUCCESSION OF OPERATORS Michael 8. Lonq <br />oivlsion oirecaor <br />APPLICATION FORM <br />The application for a Transfer of Permit and Succession of Operators must contain four <br />t4) major parts: 1) an Application Form; 2) an Application Fee; 3) a Performance <br />Warranty (attached as part of the Application Package) hearing the original notarized <br />signature of the Successor Operator; and, 4) a replacement Financial Warranty provided <br />by the Successor Operator, bearing an original notarized signature. To expedite <br />processing, please provide the information in the format and order described below. <br />I. ADMINISTRATIVE INFORMATION <br />1. Permit Number: M 8 6- O ~ C~ <br />2. Operation Name: ~N C X45 Wt INS <br />3. Current Permitted Operator: <br />Contact Person: Bob H/~~ <br />Company Name: D G s~ C <br />Street: ~o Bon 46 , 221 8 2.~c~s M1N~ IZORo <br />City: tF45WRus. <br />State: C_p Zip Code: 8)326 <br />Area Coder ~ Telephone: <br />4. Successor Operator: <br />Contact Person: Jl~v, /JL°A~L°/' <br />Company Name: _Qeq~weod GoIG~/)1iMn /4Cy <br />Street: ~c~ SHG7 "3l <br />c;ty: ~ ~F,akm~~~~dN <br />State: ~~ /I7. Zip Code: 7`/a~ <br />Area Code: _5'OS Telephone: 6 3~- ~~27G <br />IRS Tax ID No. or Social <br />...- Security No.: <br />S'03G 3 ~ <br />~~ <br />5. Application Fee: $100.00 <br />Make check payable to the Division of Minerals and Geology ~ DV ` Nb'N~ <br />out s~ulnd~h <br /> ~1-F = \'Z-~31~02 <br />