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STATE OF COLORADO <br /> DIVISION OF RECLAMATION,MINING AND SAFETY <br /> Department of Natural Resources <br /> 1313 Sherman St.,Room 215 D O L S RA D O <br /> DIVISION O F <br /> Denver,Colorado 80203 RECLAMATION <br /> Phone:(303)866-3567 MINING <br /> FAX:(303)832-8106 _&— <br /> SAF ETY <br /> APPLICATION FORM <br /> FOR TRANSFER OF MINERAL PERMIT AND <br /> SUCCESSION OF OPERATORS <br /> ADMINISTRATIVE INFORMATION <br /> Permit Information <br /> Permit Number: M- ti qq y- OS 3 RECEIVED <br /> Operation Name: T) C,01?_ ����{���-S C V rILLNeA ?k� 1 GCT 17 2016 <br /> Permittee Information <br /> 14kim of Reclamatim <br /> Contact Person: —rpn\-1 �, �p�� l�Z Mining&Safety ' <br /> Company Name: k2)"'L, , QY Ci�u c II <br /> Street Address: <br /> City: M0Y►�yUSe <br /> State: Lncc' ,c) Zip: 9 1110:2 <br /> Phone: (c::I(,) ay q- ()l o 1 <br /> Email(optional): <br /> Prospective Successor Information W� <br /> Contact Person: ,2 t1r <br /> company <br /> 8�11 a <br /> mpy Name: <br /> Street Address: ca n ci(q S cj�(�, ' ' �' <br /> City: cylbi y-os:e ✓ JV0 nif, <br /> State: C-0�dYcc(A(> Zip: S )q o-2) <br /> Phone: ( 9-7 C) ) a 9 - I D t_n <br /> Email(optional): <br /> Office of Office of <br /> Mined Land Reclamation Denver•Grand Junction•Durango Active and <br /> Inactive Mines <br />