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~ - <br />-2- <br />Q. ADMINISTRATIVE INFORMA'T'ION: <br />I. Permit Number: <br /> <br />2. Operation Name: <br />3. Cumpt Perniitfsd Ocerator. <br />V. F ~~tl+ 1. ~--~ ~5 <br />C <br />P ~ <br />I <br />ontact <br />erson: ~~f C <br />r --t ( In i <br />; <br />_ , <br />p <br />Company Name: ~~ , <br />~ <br />7 <br />~~-.~ `~'/a '~ ~,j <br />Street: (C9z0 ['_,~ L'~' <br />city: f-h~ <br />stag: (~ <br />Zip C <br />ode: ~ t` <br />Area Cade: 9 ~o c~ <br />Telephone: ~ 05 ~ ~1 <br />4, Suoceaaor Operator. <br />Contact Person: <br />Company Nerve: <br />sue: <br />City: <br />State: <br />Area Code: <br />II2S Tax ID No. or Social Security No.: <br />~~S01J t~IV~ <br />~a'tM,t <br />~u~~ <br />Cb ~ <br />/~~`O~o Zip Cade: f~j'ox~Z <br />J ~I..LL Telephone: ~ ~~ - `t Z~ <br />5. Application Fee: $700.00 for Hard Rock operations; $125.00 f Construction Materials operations <br />Make check payable to the Division of Minerals end Geology <br />