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I. ADMINISTR4TIVE INFOR~IATiON: <br />1. Permit Number: <br />2. Operation Name: <br />3. Current Permitted Ooeratar: <br />Contact Person: <br />Company Name: <br />street. <br />Citv: <br />State: <br />Area Code: <br />4. Successor Ocerator: <br />Contact Person: <br />Company Name: <br />Street: <br />City. <br />State: <br />Area Code: <br />IRS Ta~c ID No. or Social Security No.: <br />~- 81-0.~ <br />~~P.l~ ~+ nlo. I <br />~1~Tr C,~N~1 <br />~/~1e5-~Gr r1 tif~lo b. le ,.l o/-E-G~er~ ~ I vt~ <br />(0099_ ~cu_~~L s2i [~.c~3c*G ~~) <br />/~i~R-~c-~i~-c~ <br />( /~, rl~~'a-inn Zip c«Ie: ~ ~Zz <br />`7 / ~ Telephone:.Z9'~ ' .Z~ ~,2 <br />~n C1Cri <br />~y~ppl~~ ~UUV151 ..L~1C. <br />~b 9~ C`~u t~.kt ~tx~ 52 I <br />C ~'~ Zip Code: ,n~ 12Z <br />~0 Telephone: yi ~-~ - "1 533 <br />'8~{ -o85~f2©d <br />5. Anolication Fee: $100.00 for Hazd Rock operations; $125.00 for Construction Materials <br />operations <br />Make check payable to the Division of Minerals and Geology <br />