REV99673

• Permit No: M1985184
• IBM Index Class Name: Revision
• Doc Date: 5/5/1998
• Doc Name: TRANSFER OF PERMIT AND SUCCESSION OF OPERATORS - APPLICATION FORM
• Type & Sequence: SO2
• Media Type: D
• Archive: No

II
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
-2-

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(~ G ~r Grp
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~o/o Zip Code: g~.7r2
q~0 Telephone :_ y~2- Z Zs7
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C~ O Zip Code: c~ 2
~"~D Telerphone: ~~~'Z- C~ ~ Sb~
or Social Security No.: 3os - ~83~5~
$100.00
Make check payable to the Division of Minerals and Geology