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- 4 - Division of Reclamation, <br />Mining & Safety <br />APPLICATION FORM FOR TRANSFER OF MINERAL PERMIT <br />AND SUCCESSION OF OPERATORS <br />Permit Information <br />Permit Number: <br />ADMINISTRATIVE INFORMATION <br />M tq 53 - I'y 1 <br />Operation Name: Ccssh 4 `ziakO Do 1% i n e <br />RECEIVED <br />MAR 30 2012 <br />Permittee Information <br />Contact Person: EtWQ- .13. Cc) 2da , C¢ ; <br />Company Name: AG G ac of s-e& <br />Street Address: 52.99 ]ETC �- • , �v-` S 15 <br />City: Gv e ie4 Liaooci V tkne- <br />State:Cot t*d o Zip: 80111 <br />Phone: peel - 79(0-1 1 aD <br />Email (optional): eCtiLOGOIrde.SCib.Ciarrl <br />Prospective Successor Information <br />Contact Person: Maf`rlc. A <br />Company Name: &,id 44 +11 Mime -s , <br />Street Address: 4 1 51 11Zennoic1:► (in, Cane_. <br />City: M614" <br />State:CO - 'd° Zip: 80503 <br />Phone: a (p5% -29$5 <br />Email (optional): qp144 4 Q 5innoix • 1 <br />/nIl, o3 <br />j.) V go/ -ooh <br />777/,70/ <br />