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STATE OF COLORADO <br />Bill Owens, Governor <br />Jane E. NORnn, Executive Director <br />Dedicated to protecting and improving the health and environment o/the people of Colo gg~- (~; p <br />4300 Cherry Creek Dr. 5. Laboratory and Radiation Services Division ~""~C:.~ t!•''6~® <br />Denver, Colorado 80246-1530 <br />Phone (303) 692-2000 <br />TDD Line (303) 691-7700 <br />Located in Glendale, Colorado <br />http://www•cdphe.state. co.us <br />8100 Lowry Blvd. <br />Denver, Colorado 80230-6928 ~v ~ ®~~ <br />(303) 692-3090 <br />pF' CO(O <br />~~ ?,b <br />rye i <br />0 <br />x <br />+ ^ <br />~` 1876 ~` <br />Colorado Deparanent <br />Bfllater Qu~;t of Public Health <br />YControlOiyisjpgp andEnvtronrrrent <br />APPLICATION FOR TRANSFER OF OWNERSHIP <br />A REVIEW OF OUR RECORDS INDICATES THAT THE ANNUAL ADMIIVISTRATIVE FEE FOR THIS PERhIIT <br />HAS BEEN PAID. THUS, SO LONG AS THE COMPLETED FORM AND EVIDENCE OF LEGAL TRANSFER <br />(EG., BILL OF SALE, COURT ORDER) IS RETURNED TO THE DIVISION BY JUNE 15, 2003, PERMIT <br />TRANSFER CAN PROCEEb WITHOUT A NEW ANNUAL FEE HAVING TO BE ASSESSEA. <br />I hereby apply for a fransfer of ownership of tlris Colorado Permit, Number CO-0027529 in San Juan County, which was <br />issued to 'unnvside Gold Cor oration. I have reviewed this permit and accept responsibilities, coverage and Liability, <br />effective 3 vo I have enclosed legal documentation of my ownership of the facility (bill of sale, court <br />order, etc.). <br />NEW OWNER: (',~~c~ Kt+v~ M rtes ~r'~JOd`r~ar <br />'-t -.__ <br />Project or Facility Name: r•~-m er ~ a.~ I„ ,,, r` o ~ ~l(~nv eat 1 /-rr~ m an~ ~ a vv~ <br />Mailing Address: per, t~sy. a <br />City: ~I ~y a_ra-.~ v~ State: ~ nI ° Nr~ c~t3 Zip: ,4) /-~ 3 3 Telephone No: (rf70) ~k7 - 5~'/ <br />n area code <br />Authorized Agent: <br />//o o~~~tber ~~ a. QQ~ <br />Facility Ad'w-ess: +/vim , J ~~ ct s~ H P. <br />City: ~l 6 dertl-~ v. State: ~~jj Zip: ~ (g ~3 Telephone No: 7t7 ~ d 7 - r~~'j 3 <br />\ area code <br />Facility County: ~~i~ v, , > u c~ .Yl <br />PREVIOUS OWNER/OPERATOR <br />As previous owner, I hereby agree to the transfer of the above-referenced permit and all responsibilities thereof. <br />Authorized Agent <br />Signature: <br />please print <br />[l ~; C-' sF~;t//n Y`i!T `-1 r~F_C,e.EFhi K" <br />Current Telephone No: 0170) r~tg 7 -~~~3 Date: ~l. / P~ e m ~ eti Q ,~ t~ x~ J <br />area Code ~ ~ fee raid <br />Facility contact C n, w,P ~ ~ a b c vo _ ___ _ <br />(if other than owner) <br />