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:
APPLICANT/OPERATOR (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: 81625
Telephone Number:
(970 1-824-2709
Fax Number:
( N/A ) -
City:
PERMITTING CONTACT
(if different from applicant/operator above)
Zip Code:
Contact's Name:
Same
Title:
Company Name:
CC: STATE OR FEDERAL LANDOWNER if an
Street/P.O. Box:
P.O. Box:
City:
City:
State:
Zip Code:
Telephone Number: [ )
Fax Number: [ 1 -
INSPECTION CONTACT
Contact's Name: Same
Title:
Company Name:
Street/P.O. Box:
P.Q. Box:
City:
State:
Zip Code:
Telephone Number: (
Fax Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER if an
Agency: NIA
Street:
City:
State:
Zip Code:
Telephone Number: ( 1 -
CC: STATE OR FEDERAL LANDOWNER if an
Agency: NIA
Street:
City:
State:
Zip Code:
Telephone Number: ( 1-