PERMFILE46709

• Permit No: M1994121
• IBM Index Class Name: Permit File
• Doc Date: 12/6/1994
• Doc Name: LIMITED IMPACTRECLAMATION 110 2 RECLAMATION PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

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9. Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: f///'//> /J/~~,.~,7i/~'T
Company Name: G///'/i~ L~iL`/~i/~P
Street: 7!~. ~~~- % ~ P~
CS tY: /-,Yn~
State: G/~Lr)1TiAtc,G~ Zip Code: yd~yi~
Area Code: 2,~r Telephone: 9r?' - ~'?:-'~`L
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: / i/'i~ ~/rf~ cJGi~~
Company Name: /_~i.Ai~ dsl°i~~s>~~
Street: i ~_~C.,- 515
City: G dd./!~
State: /lL/>r'~R7L~ Zip Code: ~~~y/~
Area Code: 30,? Telephone: ~ct~ ~~s-i~~.~j~
INSPECTION CONTACT
Individual's Name: 1 /,//"//> /~i~SQ~/>~7
Company Name: /~i~'i~ /Jil~rJUd`z
Street: ~/,7_ l~iw 9_?ST
City: / /n ~<
State: ~~)~i~C~ Zip Code: ~/~j /~
Area Code: z~ Telephone: 5~? - D,-.T ~~
CC:•;. STATE OR FEDERAL LANDOWNER (if any)
i
y`~ency:
RE~IPT ate IZ-- ~ '191_No. 1526 _
Received From
Addre s
~ ~~~~ ollars $ ~~S•
a FOr - Z _
m
m
ACCOUNT HOW PAID
AMT. OF CASH _
ACCOUNT
AMT. IAID CHFCK ~ Y ,} I ~ _