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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY C <br />Department of Natural Resources (�� <br />1313 Sherman St., Room 215 COLORADO <br />D I v 1 S S 1 ON OF <br />Denver, Colorado 80203 RECLAMATION <br />Phone: (303) 866 -3567 MINING <br />FAX: (303) 832 -8106 —&— <br />SAFETY <br />APPLICATION FORM <br />FOR TRANSFER OF MINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />ADMINISTRATIVE INFORMATION <br />RECE11'r-- <br />DEC 10 2013 <br />Permit Information <br />Division of ReclanEa;;on, <br />Permit Number: M- 1992 -045 <br />Mining & Safety <br />Operation Name: Gold Basin Mine <br />Permittee Information <br />Contact Person: James Van Ella <br />Company Name: N/A <br />Street Address: 180 LN 200 Bass Lake <br />City: Angola <br />State: I N Zip: 46703 <br />Phone: ( 260 ) 665 -7060 <br />Email (optional): <br />Prospective Successor Information <br />Contact Person: Laurens Leffingwell <br />Company Name: Gold Basin Mine, LLC <br />Street Address: c/o Simpson Estates, Inc., 30 N. La Salle St., Ste. 1232 <br />City: Chicago <br />State: IL <br />Zip: 60602 <br />Phone: ( 312 ) 726 -3110 <br />Email (optional): ton @simpsonestates.com <br />►t <br />Office of Office of``,!' <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and Y� Y V Inactive Mines ,fv <br />