REV95722

• Permit No: M1977151
• IBM Index Class Name: Revision
• Doc Date: 11/28/1989
• Doc Name: REQUEST FOR TRANSFER OF MINERAL PERMIT AND SUCCESSION OF OPERATORS I RECITALS
• Type & Sequence: SO2
• Media Type: D
• Archive: No

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10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
PERMITTING CONTACT

O. ~ ^ /So 1
~~~n f''2 ~/n Zip Code: gQG~ /
,~_ Telephone: (, S^9.' `) S-Y2
(if different from applicant/operator above)
Individual's Name: ,rj'~y,kp ~S )~~,~
Company Name:
Street:
City:
State:
Area Code:
Telephone:
Zip Code:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name: s1 n, e ~ t z bn.-r
Company Name:
Street:
City:
State:
Area Code: Telephone:
Zip Code:
11. Primary future Cropland(CR) Pastureland(PL) General Agriculture(GA)
land use - Rangeland(RL) F restry(FR) - Wildlife Habitat(WL)
(check one): - Residential(RS) - Recreation(RC) - Industrial/Commercial(IC)
Developed Water ~sources(WR) = SSolid Waste Disposal(WD)
12. Primary present Cropland(CR) Pastureland(PL) t~ general Agriculture(GA)
land use - Rangeland(RL) - Forestry(FR) -" Wildlife Habitat(WL)
(check one): -
Residential(RS1 - Recreation(RC) - Industrial/Commercial(IC)
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Developed Water l~sources(WR)
To the best of my knowledge, all the information presented on this application form and
the attached Exhibits A-P are true and correct (must b~igned by applic~a t/ope~r~Jator).
Date: ~llll 02 S~~-~ By: „l ¢2- ((r~l/l /~ (~_3k-..~/(/~
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