REV00167

• Permit No: M1981154
• IBM Index Class Name: Revision
• Doc Date: 7/9/1992
• Doc Name: REGULAR OPERATION 112 RECLAMATION PERMIT APPLICATION FORM
• Type & Sequence: CN1
• Media Type: D
• Archive: No

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Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: Mike Horner
Company Name: San Miguel County
Street: 1120 summit PO Box 426
Cjty; Norwood
State: _ Colorado Zip Code: 81423
Ared Code: 303 Telephone: [phone]
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name: _
Street:
City:
State:
Area Code:
INSPECTION CONTACT
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:

Telephone:
Zip Code:
Zip Code:
Telephone:
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency: _
Street:
City: _
State:
Area Code:
Telephone:
Zip Code:
CC: STATE OR FEDERAL LANDOWNER (if an v)
Agency: _
Street:
City: _
State:
Zip Code:
Area Code: _ Telephone: