2015-11-12_REVISION - M1979010

• Permit No: M1979010
• IBM Index Class Name: REVISION
• Doc Date: 11/12/2015
• Doc Name: Application AM02
• From: Avery Pit
• To: DRMS
• Type & Sequence: AM2
• Email Name: DMC
• Email Name: GRM
• Media Type: D
• Archive: No

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11. Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Contact's Name:
Company Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Number:
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Title: Prt.,si°C -4-
P.O. Box: Po Q o,v ( $
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(1(q )- S-_3%•1 40
Zip Code:
( ') (1 ) - -gets - 3') 9' K/
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name:
Company Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Number:
INSPECTION CONTACT
Contact's Name:
Company Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Number:
e l o, 1/110 o c �e
4c P,o du cis, ' v.c
SLS u t VQ !/t's-t-c(
Title: C -o A4r`a l (t r
P.O. Box: AC) Ao u / .
0
( 1) (9 )- 3(4S-')90
( 'ti (°► )- Sas - 3 4)9'1
Zip Code: o\- 1
1'1/1, CAA a e 4• L o (-c v .a ✓i
14G f/ r
Crrt g9 '✓-e
rto (/•• Sf-oi
CC)
Title: rr`'e Sid e44
( t q )- 393- V>90
( 7(9' )- R94S-314 S/
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State:
P.O. Box:
iDO 8.0)( / U'l
Zip Code: O (oZ 1 1
Zip Code:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State:
Telephone Number:
Zip Code:
( )-