2014-12-17_REVISION - M1994114

• Permit No: M1994114
• IBM Index Class Name: Revision
• Doc Date: 12/17/2014
• Doc Name: Conversion Application
• From: Kagan and Son, LLC
• To: DRMS
• Type & Sequence: CN1
• Email Name: TOD
• Media Type: D
• Archive: No

-3-
11. Corresaondence Information:
APPLICANVOPERATOR (name,address,and phone of name to be used on permit)
Contact's Name: Alldy Kagan Title: Owner
Company Name: Kagan and Son, LLC
Street/P.O.Box: 555 Ernest Avenue P.O.Box:
City: Westcliffe
State: CO Zip Code: 81252
Telephone Number: (719 1- 783-9636
Fax Number: (719 )_ 783-9636
PERNUTTING CONTACT (if different from applicant/operator above)
Contact's Name: Ken KIco Title:
Company Name: Azurite, Inc.
Street/P.O.Box: P.O.Box: 338
City: Cotopaxi,
State: CO Zip Code: 81223
Telephone Number: (719 _ 942-4178, cell 719.207.3973 e-mail azurite @wildlblue.net
Fax Number: (719 _ 942-4178
INSPECTION CONTACT
Contact's Name: Andy Kagan Title: Owner
Company Name: Kagan and Son, LLC
Street/P.O.Box: 555 Ernest Avenue P.O.Box:
City: Westcliffe
State: CO Zip Code: 81252
Telephone Number: (719 _ 783-9636
Fax Number: (719 )_ 783-9636
CC: STATE OR FEDERAL LANDOWNER(if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-
CC: STATE OR FEDERAL LANDOWNFR(if anv)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-