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- <br />3. Crrrwt Permgled Operator: <br />Captact Pasco: <br />Campmy Nam: <br />so-eet: <br />Ciry: <br />sere: <br />Alta Code: <br />4. Spaasor Operator. <br />Captad Palm: <br />Compepy N®e <br />3treeC <br />cry: <br />State: <br />Alta caae: <br />1RS Tax ID No. or Social Seca¢iry No.: <br />Am,'~k P; t <br />~~~~rta K. Cy«.fso.z <br />S YO C,P ~'` N ~d gaX /OSG <br />BB,(fe /' <br />~e/oral,~o z~coae: A/6H/ <br />97o Tekp6ope: ~7F3 ^ ,S8 q~ <br />1JOG P lON,QA/JO <br />/~1,C~=~t!Q' sgyD ,~. ~P,s..eL ,:vie. <br />4~.si .P/Jc ~5~ s~0, f or 7sro <br />~~~~E~ <br />~~ tip Code: B/~/ ~ / <br /><g 70~ rekphme: ~78 - 36 7 / <br />~~-0 549 ~iZ. <br />5. Apptlptbn Fee: S 100.00 for Hard Rock operetiwu; 5125.00 far Capstntction Materials opaetbas <br />Make check payable to tLe Divisim of Mmerels and Geology <br />