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Your Address* <br /> 520 Cascade Dr <br /> Your Address 2 <br /> Your City <br /> Golden <br /> Your State <br /> CO v <br /> Your Zip Code <br /> Maximum of 10 digits. (Example) 80202 <br /> 80403 <br /> Email Address <br /> Enter a valid email address in this field to receive a confirmation e-mail. <br /> camilledj@yahoo.com <br /> Your Phone Number* <br /> Used only to follow up. <br /> 7075900303 <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 /> O Mineral Owner Nearby Resident <br /> ❑ Adjacent Land Owner Concerned Citizen <br /> Government Agency ❑ Other <br />