1997-10-23_REVISION - M1977170

• Permit No: M1977170
• IBM Index Class Name: Revision
• Doc Date: 10/23/1997
• Doc Name: CONSTRUCTION MATERIALS REGULAR 112 OPERATION RECLAMATION PERMIT APPLICATION FORM
• Type & Sequence: AM1
• Media Type: D
• Archive: No

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Correspondence Information:
APPLICANTfOPERATOR (name, dd~r)ess, and phone
Contact's Name: N /~~ ~ f1
Company Name: /'~7~/L~[~ ~
Street: ~(UG J `~' S
City : ,S/9L/QA
State: ~.~-0~14Q~ Zip Code: ~~~1
Telephone Number: (7~~ ) - J3~ - 2a al
Fax Number: ( ) -
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: Title:
Company Name:
Street:
City:

Slate:
Telephone Number: ( ) - _
Fax Number: ( ) -
INSPECTION CONTACT

Contact's Name: ~~
~
Company Name: n. l p //
~A6'/ (~!//u

Street: v
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Ti
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y9c i Oq
City: p
State: G'y/1~~~'0~ )L1 Zip Code: O~y~~
Telephone Number: ( 7f7 ) - J J / - L~ S2
Fax Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if an
Agency:
Street:
City:
State:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if anv)
Agency:
Street:
City:
State:
Telephone Number:
Zip Code:

o~ftntame to be used on erm
`'~/ itle:
T/ducTiv~~ Cpiy~Q~O
H 161/rV.~ ~/ /~. SD
t)
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Zip Code:
Zip Code: