2012-05-03_REVISION - M1999021

• Permit No: M1999021
• IBM Index Class Name: REVISION
• Doc Date: 5/3/2012
• Doc Name: TRANSFER OF PERMIT & SUCCESSION OF OPERATORS APPLICATION FORM
• From: TROLLCO
• To: DRMS
• Type & Sequence: SO3
• Email Name: MAC
• 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-
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Zip Code: giala/
Telephone: 3(0 — �l� t�
4. Successor Operator:
Contact Person: X JOr Jeokrei a.c5 r
Company Name: hie A0, fA)G
Street: / e o
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City: i fil cYSO I"
State: G 4/ o Zip Code: 005:_.S'" 0
Area Code: 9 7 (/ � Telephone: V o
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IRS Tax ID No. or Social Security No.: �" — (fq — 822 2'
5. Aonlication Fee: 5115.00 for Hard Rock operations; 5144.00 for Construction Materials operations
Make check payable to the Division of Reclamation, Mining and Safety