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2- <br />_~ ~.~ ~. yu ~ ~ ~,_, _r <br />1. Permit Ntmmber: <br />2. Operation Namc: <br />m -~ g -oo~ <br /> <br />3 <br />C~tact Person: <br />Compmry Name: <br />Strect: <br />City: <br />state: <br />Area Code: <br />4. Spocesaor Operator. <br />Contact Parser: <br />Compmry Nam: <br />Street <br />City: <br />State: __ -- _ -._- _ <br />Area Code: <br />IItS Tax ID No. or Social Security No.: <br />- `- ~ S.l_1... m AC~- <br />MaFFii~ Co•n.t~ ~oh~ ~~PT• <br />E3 2-2 ~. l so- .S~st- <br />Qo.t~ny_ r,t_-1 <br />CRFk.i C-t <br />C.o Zip Code: g I (0 2 S <br />`1 ~ ~ Telephone: 8 'Z4 '~ J 2. l l <br />SiC,UE F3AKlYL <br />33 ~rc~ErLP2.rs€S ,t~L <br />1 zoo ~. l S-~ S'ta6E.r' <br />C 2~~= C-1 <br />--- -~- - Zip Code: $ ~ laz,~ <br />~ ~ ~ Telephone: 8 Z4 - o Z ZS <br />4-l -o g~fl 8b <br />5. Apptkatiop Fee: $ 100.00 for Hard Rock operations; S 125.00 for Construction Materiels operations <br />Make check payable to the Division of MmeraLs and Geology <br />