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STATE OF COLORADO <br />DMSION OF RECLAMATION, MINING AND SAFETY <br />Deparhnert of Natural Resources S003 <br />1313 Sherman SL, Room 215 <br />Denver. Colorado 80203 <br />phone: (303) Bss -3587 <br />FAX (303)832 -8106 <br />fovk41'4' APPLICATION FORM <br />FOR TRANSFER OF MINERAL PERMIT AND <br />SUCCESSION OF OPERATORS <br />ADMINISTRATIVE INFORMATION <br />Permit Information 19 t t— ©Z 3 <br />Permit Number. M' <br />operation Name: Caliche School Pit <br />Permittee Information <br />Contact Person: Clyde Couch amA ftAdA i Coac M <br />Company Name: <br />Street Address: 122 State Street <br />city: Sterling <br />State: CO <br />Phone: V70 ) 522 -1239 <br />Email (optional): <br />Zip: <br />Prospective Successor Information <br />Contact Person: Kristine M. Couch <br />80751 <br />Company Name: <br />Street Address: 6963 S. Olive Way <br />city: Centennial <br />State: CO Zip: 80112 <br />Phone: (303 )618-5111, Fax 303 - 694 -4204 <br />Email (optional): kristinemcouch @msn.com <br />office of <br />WnW lard Reclamation <br />Inactive Mines <br />Denver - Grand JunGlon - Durango <br />COLORADO <br />DIVISION Of <br />RECLAMATION <br />MINING <br />SAFETY <br />' �C�e'VED <br />o APR 252013 <br />�VISIOI y pF ac.,, _ <br />Moe of <br />Ache and <br />6/-- <br />NoV 'ev <br />Afe- O'Le =3 /bey <br />