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. ADMINISTRATIVE INFORMATION: <br />1. Permit Number: <br />-~ 2. Operation Name: <br />3. Current Permitted Operator: <br />- - ~ coat-act Person: - <br />~ompany Name: <br />Street: <br />City: <br />state: <br />Area Code: <br />4. Successor Operator: <br />Contact Person: <br />Company Name: <br />street: <br />_ city: <br />State: <br />Area Code: <br />~F~ <br />~ DYi . , <br />~'Prd ~/g <br />~S <br />N1-19$~ -~~~~, <br />S~~ .e, ~ ~ ~~f <br />t~rl.. .~~~~. ~' ~~ <br />..3~~1a C-~ /~ _ ~ <br />1 Or' ~ Zip code: rk~~[L <br />%~ Telephone: ~ // <br /> <br />IRS Tat ID No. or Social Security No.: <br />/%~I~P~_~Y%7~7LYY.c~ ~C <br />OS ~4~ ` ~ ~ , l~~ri7~~ <br />- .T1/url~~e <br />~ Zipy~CodQe;~ /~l <br />-L~ Telephone: %~O /P~O'~ <br />a~-o~9~~ <br />5. Application Fee: $100.00 for Hazd Rock operations; $125.00 for Construction Materials <br />operations <br />Make check payable to the Division of Minerals and Geology <br />