1. (a) Name of Permittee.      

    (b) Address.  Street     
           City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin       Zip
           Telephone     Fax

    (c) Mining Permit Number.

    (d) Date of Permit Issuance (and any Amendment).

    (e) Mineral(s) Mined.

    (f) State and Federal Mineral Lease Numbers.

2. Time period covered by the report.
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