REV106065

• Permit No: M1977057
• IBM Index Class Name: Revision
• Doc Date: 6/25/1998
• Doc Name: TRANSFER OF PERMIT AND SUCCESSION OF OPERATORS APPLICATION FORM
• Type & Sequence: SO2
• Media Type: D
• Archive: No

-2-
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:
c; ty:
State:
Area Code:
IRS Tax ID No.
5. Application Fee
_~ _ 7~-oSz
F<oir` L P i~
C' G6o^~ ~F/1~iE L
o ,,. F /~
R.¢, G
co . Zip Code:
Telephone:

~? O. 1~~x ~6.Sn
' ~a Zip Code: ~~
/r/ Telephone: _i ~9- 8/~
or Social Security No.: ~'f -n1-~.3 - 6~0 .
$100.00
Make check payable to the Division of Minerals and Geology