2008-06-20_REVISION - M1996052

• Permit No: M1996052
• IBM Index Class Name: REVISION
• Doc Date: 6/20/2008
• Doc Name: SO Application Form
• From: L.G. Everist, Inc.
• To: DRMS
• Type & Sequence: SO2
• Email Name: MET
• Media Type: D
• Archive: No

-2-
ADMINISTRATIVE INFORMATION:
1. Permit Ntimber:
2. Operation Name:
3. Current Permitted Operator:
Contact Person:
Company Name:
Street:
City:
State:
Area Code:
4. Successor Operator:
Contact Person:
Company- Name:
Street:
Citv:
State:
Area Code:
IRS Tax 1.1:) No, or Social Security No.

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K FAD Y M ? x? GaN C2?'t-E Goy-tPA? y
W ASf41VE7TbN ST
C.? Zip Code: OZ ?o
J 03 Telephone: Z ?Z `17?/
LYNN m SouLT,
L.Q. ?VEQ4???2A-c?
-73 2 E. $g- AuE-. S V f zC 260
C C) Zip Code: _.-.SMb
30 _ Telephone: _ tab Z-2-q
5. Application Fee: $115.00 for Hard Rock operations; $144.00 for Construction Materials operations
Make check payable to the Division of Reclamation, Mining and Safety