2016-01-22_REVISION - M1986102

• Permit No: M1986102
• IBM Index Class Name: REVISION
• Doc Date: 1/22/2016
• Doc Name: Application AM01
• From: Dan Collins / Collins-More-head, LLC
• To: DRMS
• Type & Sequence: AM1
• Email Name: LJW
• Email Name: GRM
• Media Type: D
• Archive: No

-2-
11. Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit) Manager
Contact's Name:
Dan Collins Title:
Company Name:
Street/P.O. Box:1417 S. Grandview Dr. P.O. Box:
State: Zip Code:
City: 85281
Arizona
Telephone Number: ! 48U
_ 206-2037
Fax Number: { --- – -
PERMITTING CONTACT (if different from applicant/operator above) Title:
Contact's Name:
Same
Company Name:
P.O. Box: _
Street/P.O. Box:
Cit}':
Zip Code:
State:
Telephone Number: ( -
Fax Number: --- -
LNSPE `TION CONTACT
Contact's Name:
Same Title:
Company Name:
P.O. Box:
Street/P.O. Box:
City:
Zip Code:
State:
Tempe
Telephone Number: ( ) -
Fax Number: ( ) - —
CC: STATE OR FEDERAL LANDOWNER if an
N/A
Agency:
Street:
City:
State:
Telephone Number: I -
CC: STAT _ OR FEDERAL LA • R anv
N/A
Agency:
Street:
City:
State:
Telephone Number:
Zip Code:
Zip Code: