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Email Address* <br /> Enter a valid email address in this field to receive a confirmation e-mail. <br /> abeierle@cityofgolden.net <br /> Your Phone Number* <br /> Used only to follow up. <br /> 3033848153 <br /> Extension <br /> Alternate Phone Number <br /> Used only to follow up. <br /> Alternate Phone Extension <br /> Connection to Operation <br /> Select all that apply <br /> Land Owner of affected land Structure Owner within 200' of affected land <br /> Mineral Owner Nearby Resident <br /> ✓ Adjacent Land Owner Concerned Citizen <br /> ✓ Government Agency Other <br /> DESCRIPTION OF COMMENT OR OBJECTION <br /> (Please be as specific as possible) <br /> Comment/Objection Narrative* <br /> see attached <br /> Permit Number* <br /> Enter valid letter and then numbers,for example M1977999, M1999777UG or C1981201. <br /> M1976007 <br /> Permitting Action Type <br /> Permit Conversion <br /> Select revision type or leave blank if comment pertains to a new permit application or NOI <br /> Permitting Action Sequence <br /> 1 <br /> Permit Type <br /> County* <br /> Jefferson <br /> Enter one county only <br /> Site Name <br /> Golden Mine <br /> Perm ittee/Operator Name <br /> Denver Brick Company <br /> ADDITIONAL INFORMATION <br /> Are there supporting photos, maps, or documents you wish to upload? <br /> • Yes No <br />