2011-06-13_REVISION - M1995057

• Permit No: M1995057
• IBM Index Class Name: REVISION
• Doc Date: 6/13/2011
• Doc Name: SO-01 application form
• From: Deborah Rudibaugh
• To: DRMS
• Type & Sequence: SO1
• Email Name: GRM
• Media Type: D
• Archive: No

II. ADMINISTRATIVE INFORMATION:
1. Permit Number:
2. Operation Name:
3. Current Permitted Operator:
Contact Person:
Company Name:
Street:
City:
State:
Area Code:
-2-
(75'7 l
_6c 2g/ eP
I Ai
e io 4Yr -CP (J Zip Code: l Z T
/ 7 0 Telephone: q� ? �/
4. Successor Operator:
/ t
Contact Person: .0 -'L � (/ /JGL (.Z(
Company Name:?
Street: 51 /
City:
State: !_
Area Code: 7 C Telephone: (� �/ / ` 6
IRS Tax ID No. or Social Security No.: _
PA( / it)
l f`
-0 IL�:^Gi•G1�i.) Zip Code:
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