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. <br />II. ADMINISTRATIVE INFORMATION: <br />1. Permit Number: <br />`I~[- ~ ~ - ~ ~3 <br />2. Operation Name: <br />3. Current Permitted Ocerator: <br />~~l ~ 14 ~) d" ~ 1 t`7(; <br />Contact Person: ~ ~" "~ ~~ ~ 'E"-2 ~!'ry/ u S ~ ~ <br />Company Name: ~j ~ a (a (c 6 Lvl4-e /' n.oT . o.~ a ~''~ N C_ <br />Street: /~~n ~~ b ~C Z ~'~o <br />City: t / y ~ a ~'G"~ <br />state: ~~ Zip code: ~~ 3 dp7/ <br />Area Code: ~ ~ Telephone: 1 ~ ~ ' 22 <br />4. Successor Operator: <br />Contact Person: r"'ll`'4 C-`~~'i~ <br />Company Name: ll.)^ ~ ~Ca~ f"~ lh , ~.. C ch D <br />'- <br /> <br />street-. ~ :~~. <br />_ 3~ ~ 3 ~g,~.¢r S~ <br />City: _ Se~.r. o.'~~O <br />State: C "4 ~ 2 ~ ~ ~' <br /> ` <br />Area Code: ~{'~~~~0~ <br />_ (~~$ <br />IRS TaY ID No. or Social Security No.: ~-t~ <br />_ 20 ` 3 r0~ ~G T <br />5. Application Fee: $100.00 for Hazd Rock operations; $125.00 for Construction <br />operations <br />Make check payable to the Division of Minerals and Geology <br />