2022-03-23_REVISION - M1991080

• Permit No: M1991080
• IBM Index Class Name: Revision
• Doc Date: 3/23/2022
• Doc Name: Request For Conversion
• From: Van Egmond Services Inc
• To: DRMS
• Type & Sequence: CN1
• Email Name: ERR
• Email Name: JDM
• Email Name: AWA
• Media Type: D
• Archive: No

-3-
1 i. �orresuondeace Iaformatiou:
RPPLICANT/OPERATOR (name,address,and phone of name to be used on permit)
e����s N�: RU Ss.�e.l c�r �ovEf.�,�e�e.,� ��t�"�`� �v`�.
Company Name: C� �Y�
Stre�t1P.0.Baz: P.t�.Box:
City: �--��-'2.�
State: �l� Zig Code: ���" �Q
Telephone Number: (� l��-_ ___ (� -1, — �� ��
�: r l- c�dldve�v : • O � 1
PERMITTING CONTACT (if different from applicantloperator above) d���h�j � • �O ��
CO�f�GYS Name: Title:
Company Name:
StreeUP.O.Box: P.d_Sox:
City:
State: Zip Code:
Telephone Number: ( 1-
F�Niitt�be�': ( )-
INSPECTION CONTACT
Con�acf's Name: �QX1�1.� C� '� C��C�I.Q� Title:
Company Name:
Stteet�P.O_Box: p.0.Box:
City:
State: �ig Code:
Telephone Number: ( }-
Fax Numbei�: i )-
CC: STATE OR FEDERAL LA_rIDOWNER(if anv)
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Street:
City:
State: Zip Code:
Telcp�ione N�ber: i )-
CC: STATE OR FEDERAL LANDO WNER(if any,�
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Street:
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State: Zip Code:
Telephone Number: ( i-