REV07575

• Permit No: M1986074
• IBM Index Class Name: Revision
• Doc Date: 4/4/1997
• Doc Name: TRANSFER OF PERMIT & SUCESSION OF OPERATORS APPLICATION FORM
• Type & Sequence: SO1
• Media Type: D
• Archive: No

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II. ADMINISTRATIVE INFORMATION:
1. Permit Number:
2. Operation Name:
3. Current Permitted Operator:
-z-

/~1- ~~ - D 7 ~-
.~o~I~rS~~~~ t'~~
Contact Person: ~ d ~ I ~
Company Name: E /'~ i C,
street: (~ 3~ ~ ~'. ~'.a //c4 c°
State: Zip Code: ~dja
Area Code: ~ 0 Telephone: ~~~ - ~ l ~
4. Successor Operator:
Contact Person:
Company Name:
Street:
City:
State:
Area Code:
IRS Tax ID No.
5. Application Fee

(,p(~jraLE~D Zip Code: ~'O'/~/
___7__L~ Telephone: -~~~~~~5
or Social Security No.: ~~~-9C~~~-5aa
$100.00
Make check payable to the Division of Minerals and Geology