2012-03-01_REVISION - M2004022

• Permit No: M2004022
• IBM Index Class Name: REVISION
• Doc Date: 3/1/2012
• Doc Name: TRANSFER OF PERMIT & SUCCESSION OF OPREATORS APPLICATION FORM
• From: ALPINE DEMOLITION
• To: DRMS
• Type & Sequence: SO1
• Email Name: PSH
• Email Name: TAK
• 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-
M r • 0 4 - ` 2 , 2
OkAVEL off /AJ
HILL 7 p 4Ck u.9 -.—i c L, fE0 61 E-✓v if
M2
tie ' L,114'er
44 bCOR
(, (7L0 RA- ,Do Zip Code: /3Os N )
Telephone: 680 - .3 - 8 2-8
4. Successor Operator:
Contact Person: -T 6• Y " 1`4.‘ TC L L
Company Name: 42 P/N& M BLED DX/ , rAi
Street: 5 ) 99c . !'�- /I 'A WAY
City: � V' h�
State: (101._ O p n %) 0 Zip Code: U r)Q O // 4'
Area Code: . Telephone: 42-/ '-.� �4
IRS Tax ID No. or Social Security No.: /34 w ` 2 0
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