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2- <br />Q. AD TAATIVEINFORMATION: <br />1. Permit N~mmber. <br />rn- ~gg~-- - ~a~ <br />2. Operation Name: <br /> <br /> <br />comet Peraoa: 'r(~C` <br />Campmry Name: T <br />street: 25a <br />City: ~~ <br />same: C-o\o~ <br />a>ea code: -~O -_ <br />4. Socrraaor Operator. <br />~LvCZo ~~`-T - <br />~LU~-icy .VAS~.2r2 _ <br />T- ~~ ~cc~c~e ~c1. <br />zip code: $OSl b <br />rdephone: ga 3- 5 t-1 ~ ~'1 <br />Contact Person: ~ f`~UtY'~ a" D2~-~h VCJ~-r t f 1 <br />co,>~y Name: C~ `~ A ~~~ <br />Strut ~ L~ . Qx~,c 2.5~<0 <br />City: (.~ mo(~'~ p <br />State: ~1 c, ,.a Zip Coda: 0~1 <br />arzacnae: fob relepnaoe: 77S-O~1 <br />iR5 Tax ID No. or Social Seaaity No.: $4 - ~ ~ a~ ~q <br />5. Apptlgtion Fee: S 100.00 for Hard Rock operations; S 125.00 fa Constmction Mmerials operetioas <br />Mske dexk payable to the Division of Minerals and Geology <br />