REV89893

• Permit No: M1986007
• IBM Index Class Name: Revision
• Doc Name: TRANSFER OF PERMIT AND SUCCESSION OF OPERATORS APPLICATION FORM
• Type & Sequence: SO1
• Media Type: D
• Archive: No

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ADMINISTRATIVE INFORMATION:
1. Permit Number:
2. Operation Name:
3. Current Permitted Operator:
Contact Person:
Company Name:
Street:
City:
State:
Area Code:
4. Successor Operator:
Contact Person:
Company Name:
Street:
City:
State:
Area Code:
IRS Tax ID No.
5. Application Fee

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CO Zip Code: ~ DS
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C ~ Telephone :_ ~~~ - ~ =' ~
C C v Zip Code: ~
~1r Telephone: 5~~
or Social Security No.: ~~~' X1`3- I(o/S
$100.00
Make check payable to the Division of Minerals and Geology
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