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ANT Ex;MSHq-CMS&H-Dist. 9 <br />/'~ <br />03-16-9c^ D2: 17PM <br />Mine safety arse <br />sport is required by law 130 C.RR ~ 411. Failure to wpert can result <br />ssment nt a civil penalty. Knowingly makings false statement can <br />in criminal prosecution under §110 of the Faders( Mine Safety antl <br />~ Act of 19J7, This report should be prepared only 4y an official <br />all knbwledl7e of ownership information. Ibis report must be sign• <br />sere indicated by straw, tb be valid. Type Or print In ink only. <br />If roots space is requiretl in any section below, um a 6epereta sheet <br />L0, rBOUirnd For now operation onlvl <br />^ Initial Notlw <br />3032315553~CU MINED LRND REC'L <br />~` Uptlala Nbtlca .~} J$G y <br />nearest town, City, and Iandrnarkl <br />r _ v /~Q• t.• ~08Z Ml nf~t~ lA MiY ,,,,~j(yXth f [`tmni Flnt'L _ <br />ne Lo®t pn tlress 5~ City 6. County 7. State B. Zip Cotle <br />flcial satinets Nematt asst t0. Telephone Number in Ti:-cominaility hype o protluet opera• <br />Event bt en Emergency lion-surface. underground or f0allltyl <br />J) <br />n at Mine in Charge pf 4lealtn an Safety l$uperinMndant ar rlnocipal O/ficed <br />me and isle }3. Address <br />Robert Weaver PO Sox 534 Gunnison Co. 81230 <br />on with Overall Responsibility tar 6 Health end SBfaty Program at Ail of the OperatbPt Minas, if tot opereror it Not Qiraotly Involved in the <br />ly Operedon of the Mina. (Selaty PirKtorJ <br />Name and Title t5. Address . <br />-Robert Weavei N CEO box 539 Gunnison Co. 822~0~ <br />oral Mine Identification Numhert df All Other MinBt In which the Sale Proprietor, Par[nenhip, Corporatlan or Other Organization has a 2Q% <br />Greater Ownership lntereat. <br />ID Numbers <br />None <br />~Jerel Mine Idantifieation Numhert of All Other Mines In whim Any Partner, Corporate Officer, Other organisation Of}iclal Or Memhar hat B <br />I%or GfBBter Ownership Interact [not applicable to sole proprietorship) . <br />' ID Numbers <br />ndress of Hecprds antl Teephone Number lSenfae o/docamen to upon the pperstpr will lM comp/ered by meiNng or persona! tervics pf the dpcu- <br />ents to shit addrets, If P.O, eox pr oenere! De/ivory Js used for mailing address, a aeparere rtreer addr9aa for p.rronal service must be provldad.J <br />I, Name of Parson to Receive Official Meil bl Service Title 18. Telephone Number <br />Robert Weatre~~ ;Oyiner) 0303} b41-15bdv <br />), Sheet AJdreas 21 . CiIY r 23, State 23, Zip Code <br />'2054 Cout~ Road '730 Gunni.~bn_)V Co. 8123b <br />1W1. Mail Address // ' :sal. City 221x). State 23(a). zip Cad <br />PO boa 53999~^`~~ 'Gunnison ~ ~Ca. 812301 <br />1, Please Check the Appropriate Box anU Complete th ,]Ileahle Section (Check only one box) <br />(, $ole Protyiet4r@ ~ II. Partnership ~ III. Corporation [~ tV. Other <br />!atibn I. 5412 PYpnrietprship <br />Trade Name o1 Company 2. Proprietpr't Name and Address of Hnsitlance <br />~0, r i'r,r+~ i~g Sto~tert Weaver_ 2054 Catme Road 73~ <br />PrpprielUr's Principal Ot}ICs Address lsvaetl 4. Gty 6. Stets B. Zip Coos <br />2054 County Road 730 ~Gunn9son - CO 31230 9 <br />Gunnison Co• 81232? <br />action 11. Partnership <br />. Tntde Narno ~~ <br /># 4 <br />