PERMFILE70159

• Permit No: M2005060
• IBM Index Class Name: Permit File
• Doc Date: 8/31/2005
• Doc Name: Reclamation Permit Application Form
• From: DMG
• To: Weld County
• Media Type: D
• Archive: No

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I1. Corresoondence Information:
APPLICANT/OPERATOR (name, address, and phone of name [o be used on permit)
Contact's Name: Greg Nelson Title: tdin;ng gn;PYpl4hT
Company Name: Weld County Public Works

Street/P.O.Box: 1111 H Street P.O.Box: 758
City; Greeley

gmte; CO Zip Code: 80632
Telephone Number: L970 )_ 304-6496

Fax Number: j 970 ) _ 304-6497

PERMITTING CONTACT (if different from applicanUoperatoraboye)
Contact's Name: Title:

Company Name:

Sncet/P.O. Box: P.O. Box:

City:

State: Zip Code:

Telephone Number: ( ) -

Faz Number: ( 1-

INSPECTION CONTACT

Contact's Name: Tile:
Company Name:
StreeUP.O. Box:
City:
State:
Telephone Number: ( ) -
Fax Number: I ) - ,
CC: STATE OR FEDERAL LANDOWNER (if anyl
Agency:
Street:
City:
State:
Telephone Number: ( 1-
CC• STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
Ciry:
State:
Telephone Number: ( ) -
Zip Code:
P.O. Box:
Zip Code:
Zip Code:
3-