REV95834

• Permit No: M1980110
• IBM Index Class Name: Revision
• Doc Name: PAGE 2
• Type & Sequence: SO2
• Media Type: D
• Archive: No

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ADM]NISTRATIVE INFORMATION:
1. Permit Number:
2. Operation Neme:
~ III IIIIIIIIIIIII III
n-BO-llo
Henderson Development
3. Currs ermlttsd Operator:
Contact Person:
Company Name:
Street:
City.
Sfate:
Area Code:
4. ~aceeasor Operator.
Goofed Perron:
Company Name:
Street:
City:
State:
Area Code:
IRS Tax A) No. or Social Security No.:
Glenn Bettis Jr.
Colo*ado.Saod-+6 .Grabal'Co.
10014 Allison Street
Broomfield
Col oradn Zip Code: R0021
303 Telephone: [phone]
D, 1lichael Callis
E-470 Public Aighvay.Authority
22470 E. 6th Pailcwav
Aurora
Colorado Zip Code: 80018
303 Telephone: [phone]
5. ,A~pGatiop Fee: 5100.00
Make check payable to the Division of Minerals and Geology