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I. ADMINISTRATIVE INFORMATION: <br />I. Permit Number. <br />2. Operation Name: <br />"~~' <br />3. ~ rtt, rrtSitted~(koeFatorc~ <br />Contact Person: <br />~~~ <br />StreeC <br />City: <br />State: . <br />Area Code: <br />~°'~;:~. <br />4. '~ . e ssor' oerator: <br />Contact Person: <br />Street: <br />City: <br />State: <br />Area Code: <br />_~. <br />(~ <br />YYl' 1 I~~1- ~~+lQ <br /> <br />~~ ~~.~. <br />IRS Tax ID No. or Social Security No.: <br />~a~,e~,`~ ~ ~u2c~ i e. ;T. I~lrr~t,~e <br />~U.~ir ~3~ <br />//ll ~~I~ /' <br />~-~ V Telephone: "~J(Sr~' ~`id~ <br />ML~~~ <br />~ii c~l~,r-~ 1. • i~i~-h n~tc~'1 ~, <br />1"~5''` ~~fn11n5 ~' ~a ~L~ <br />Zip Code: <br />~$-1L12stit <br />5. Anolication Fee: $100.00 for Hard Rock operations; $125.00 for' Construction Materials <br />operations. <br />Make check payable to the Division of Minerals and Geology <br />~_ Telephone: .a ~ 5 - ~ ~`-i <br />