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<br />RECEIVED <br />MAY 04 X06 <br />_ 2 _ glvtslan of Minarata and Geology <br />II. ADMINISTRATIVE INFORMATION: <br />1. Permit Number: <br />2. Operation Name: <br />3. Correct Perwltted Operator. <br />Jx~G'cfraa ~ tL' `f,-L~~f,~//P~ lYltl~Ar _ itn/>'/i /IiSBll~,r <br />Contact Person: j~'9 l V ~f~il~tl~ <br />Company Name: <br />street: ~~ ~~L~~i <br />city L~~vSt C~ <br />state: f `~1s -- Zip Code: _1~(~,2 ZC~ <br />Area Code: Telephone: <br />4. Soceeswr Operator. <br />Contact Person: <br />Company Name: <br />Street: <br />c;ty: <br />state: <br />Area Code: <br />~~,~ ~~~~ <br />,~1~/5 <br />-(~nt~~ zip c«lc: <br />j~3 Telephone: $3. ~ _ S b `d <br />IRS Tax ID No. or Social sectnity No.: _ ~j oZ 3 . Ky ~~.~ ~ <br />5. Appikatbo Fee: S 100.00 for Herd Rock operations; 5125.00 for Construction~INaterials operations <br />Make check payable to the Division of Minerals and Geo]o~ <br />