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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone. (303) 866-3567 <br />FAX: (303) 832-8106 <br />STATE OF COLORADO <br />APPLICATION FORM <br />FOR TRANSFER OF MINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />Permit Information <br />Permit Number: <br />ADMINISTRATIVE INFORMATION <br />M VIW7 -072_ <br />Operation Name: LEE NO Z. PL4CEK <br />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />— &— <br />SAF ETY <br />RECEIVED <br />6" <br />SEP 14 2015 - <br />DNS <br />Permittee Information <br />SlAEY J CoNNfig, <br />Ee Name: &TANL81 J CON NW, <br />Contact Person: <br />City: <br />State: <br />Phone: <br />1 <br />VCi. <br />(30.3 <br />Email (optional): <br />)72-10/_3 <br />Zip: 502/0 <br />liti)14Pit/11) <br />1v <br />Street Address:IP' <br />Prospective Successor Information <br />Contact Person: TNOUtS MOSCiA / VALERIE MUSCi <br />.empa y Name:: 11401,4 AS N1VSCu / %/1 LERIE MUSCIA <br />Street Address: b 14 AMERICAS Wim 3"17.3 <br />City: BOX ELDER. <br />State: ED <br />Zip: -51111 <br />Phone: (720 ) 483- /2O'7 <br />Email (optional): VMuSCi•r o RocLT i IE, Cow\ <br />Office of <br />Mined Land Reclamation <br />Inactive Mines <br />Denver • Grand Junction • Durango <br />Office of <br />Active and <br />