2017-03-06_REVISION - M1999018

• Permit No: M1999018
• IBM Index Class Name: Revision
• Doc Date: 3/6/2017
• Doc Name: Request for Conversion
• From: Wagner Construction
• To: DRMS
• Type & Sequence: CN1
• Email Name: ACY
• Email Name: GRM
• Media Type: D
• Archive: No

-3-
11. Correspondence Information:
APPLICANTIOPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: Jay Wagner
Title:
Company Name: Wagner Construction, Inc.
Street/P.O. Box: 1850 East 1 st
P.O. Box:
City: Craig
State: Colorado
Zip Code: 81525
Telephone Number: ( 970 1-824-2709
Fax Number: ( NIA } _
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: Same
Title:
Company Name:
Street/P.O. Box:
P.O. Box:
City:
State:
Zip Code:
Telephone Number: ( )
Fax Number. -
INSPECTION CONTACT
Contact's Name: Same
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: NIA
Street:
City:
State:
Zip Code:
Telephone Number:
CC:--STATE-OR FEDERAL LANDOWNER (if any)
.
Agency: NIA
Street:
City:
State:
Zip Code:
Telephone Number: �� -