2021-04-05_REVISION - M1978079

• Permit No: M1978079
• IBM Index Class Name: REVISION
• Doc Date: 4/5/2021
• Doc Name: Request for Conversion of Permit
• From: Lincoiln County
• To: DRMS
• Type & Sequence: CN1
• Email Name: DC1
• Email Name: JLE
• Email Name: AWA
• Media Type: D
• Archive: No

-3-
11. Corresaondence Information:
APPLICANT/OPERATOR (name,address,and phone of name to be used on permit) I
Contact's Name: 1&1-4 1 J4r4u Title:L."Ind U50AA M ox .
Company Name: L,., . ih Lau-t�U
Street/P.O.Box: \D-�,— - cC1, ��,e P.O.Box: l
City: _
State: Zip Code: f30f32/
Telephone Number: ( 1 Ot
Fax Number: ( 11 O(
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: S A rn e Title:
Company Name:
Street/P.O.Box: P.O.Box:
City:
State: Zip Code:
Telephone Number: (Fax Number: ( )-
INSPECTION CONTACT
Contact's Name: �. P_ Title:
Company Name:
Street/P.O.Box: P.O.Box:
City:
State: Zip Code:
Telephone Number: ( )Fax Number: ( )-
CC: STATE OR FEDERAL LANDOWNER if an
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-
CC: STATE OR FEDERAL LANDOWNER(if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( )-