2014-07-23_REVISION - M1989095

• Permit No: M1989095
• IBM Index Class Name: REVISION
• Doc Date: 7/23/2014
• Doc Name: Conversion application CN01
• From: Phillips County
• To: DRMS
• Type & Sequence: CN1
• Email Name: ERR
• Email Name: TAK
• 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: Randy Schaff
Title: County Planner
Company Name: Phillips County
Street/P.O. Box: 221 S. Interocean
P.O. Box:
City: Holyoke
State: Co
Zip Code: 80734
Telephone Number: ( 970 _ 854 -3778
Fax Number: ( 970 _ 854 -3811
PERNUTTING CONTACT (if different from applicant/operator above)
Contact's Name: Same as above
Title:
Company Name:
Street/P.O. Box:
P.O. Box:
City:
State:
Zip Code:
Telephone Number: ( )
Fax Number: ( ) -
INSPECTION CONTACT
Contact's Name:
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: Same as above
Street:
City:
State:
Zip Code:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State:
Zip Code:
Telephone Number: ( 1-