2014-06-03_REVISION - M2004023

• Permit No: M2004023
• IBM Index Class Name: Revision
• Doc Date: 6/3/2014
• Doc Name: Conversion Application
• From: Phillips County
• To: DRMS
• Type & Sequence: CN1
• Email Name: TAK
• Email Name: ERR
• Media Type: D
• Archive: No

-3-
11. Correspondence Information:
APPLICANT/OPERATOR (name,address,and phone of name to be used on permit)
Contact's Name: moldy Scha%r Title: Planner
Company Name: Phillips County
Street/P.O.Box: 221 S. Interocean Ave. P.O.Box:
City: Holyoke
State: co Zip Code: 80734
Telephone Number: (970 _ 854-3778, Cell 970-520-0502
Fax Number: (970 _ 854-3811
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: Title:
Company Name:
Street/P.O.Box: P.O.Box:
City:
State: Zip Code:
Telephone Number: ( )Fax Number: ( )-
INSPECTION CONTACT
Contact's Name: Same as above Title:
Company Name:
Street/P.O.Box: P.O.Box:
City:
State: Zip Code:
Telephone Number: ( )Fax Number: ( )-
CC: STATE OR FEDERAL LANDOWNER(if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-
CC: STATE OR FEDERAL LANDOWNER(if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-