REV01413

• Permit No: M1978072
• IBM Index Class Name: Revision
• Doc Date: 1/2/1996
• Doc Name: LIMITED IMPACT OPERATION RECLAMATION PERMIT APPLICATION FORM
• Type & Sequence: AM1
• Media Type: D
• Archive: No

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10. Correspaindeace Information:
APPLICANT/OPERATOR (name, address, sad phase o£ name /to~~be~~~us~ed-won permit)
Coatact's Name: ~~ Clog ~~-~tle: Sarrat.ary
Company Name: Lincoln County
Street: 10,3..~r~ crroo+
City: E(u 3 c
State: Colorado Zip Code: 80821
Telephone Number: ( 719 ). _ 743-2337
Fax Number: ( 1 -
PERMISTI2iG CONTACT (i£ di££erent fro® applicant/operator shave)
Individual's Name: Title:
Individual`s Name:
Compaay Name:
Street:
City:
State:
Telephone Number:
Fax Number:
INSPECTION CONTACT
Company Name: i.; nrn7 n Cnunty v
Street: inz ~r~
City: H u cs o
State: (`nlnradn Zip Cade: 80821
Telephone Number: ( 719 ) - 743-2337
Fos Number: (_ ) -
~: STATE OR FEDHRAL LADIDURNSR (if soul
A4~cY= .
Street:
City:
State:
Telephone Number: ( 1 -
CC: STATE OR FEDERAL LADIDORRER (if aav)
Agency:
Street:
City:
State:
Zip Code:
Zip Code:
Zip Code:
Telephone Number: