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• • III IIIIIIIIIIIII III <br />MINED LE1ND RECLAMATION DIVISION <br />Department of Natural Resources <br />t373 Sherman St., Roam 275 <br />Denver. CO 80203 <br />303 866-35ii7 <br />Fax: 303 83?-8706 <br />a <br />~, <br />STATE OF COLORADO <br />~~.Lit!~~.a <br />JN 15 1992 <br />pF Cpl <br />~~_ p~9 <br />FQ;' ~ ~ <br />~ Y <br />.+,,~V ;, <br />~ /e]6 ~ <br />Mined Cana <br />TRANSFER OF PERMIT AND SUCCESSION OF OPERATORS <br />APPLICATION FORM <br />Roy Romer. <br />Governor <br />Fretl R. Banta, <br />Division D~rcctor <br />The application for a Transfer of Permit and Succession of Operators must contain three <br />,. (3) major p;~rts: 1) an Application Form; 2) a Performance Warranty (attached as part of <br />the Applica~:ion Package) bearing the original notarized signature of the Successor <br />r Operator; and, 3) a replacement Financial Warranty (for the amount maintained by the <br />' current pernittee> provided by the Successor Operator, bearing an original notarized <br />signature. To expedite processing, please provide the information in the format and <br />order described below. <br />SO -ob 3 <br />I. ADMINISI~RATIVE INFORMATION <br />1 . Permit Number: /}'~ _ ~'J, n,~~ /~~,,,, c; o.; e J d - d X13 <br />2. Operation Name: ~f~ul_.~~ ~"f <br />3. Current Permitted ODerator: <br />Contact Person: „ ' <br />Company Name : ~.s ~fR ~e R 1 Td /--~.~.(~~_ <br />Street: ad~Gu~ (!~-~`--5~- Gc/ _ .5~7` <br />city : yea ~ s B S r` o r,~' ,C.~, ~ _..L.. ~_ <br />State: ('X/1A~~' y3oa3 ~~- Zip Code: ~30 <br />Area Code: ~bS'- </~3-703/ Telephone: <br />4. Successor ODerator <br />Contact Person: ~~ ~ e <br />Company Name : r ~,( K / .c,/..~`-, ,~j~ <br />Street: T.~ ~ ~~ ~ .~f <br />City: ~~"/~//~~ <br />State: ~i , , Zip Code: Q3 3 <br />Area Code: ~f?.~ Telephone: C~l/~.3 - X03 / <br />[RS Tax ID No. or Social Security No.: 33- (n/D 1 ~5~, <br />5. Ap >:,cation Fee: 5100.00 <br />