2004-02-03_REVISION - M1981088

• Permit No: M1981088
• IBM Index Class Name: Revision
• Doc Date: 2/3/2004
• Doc Name: 112 Appl Form
• From: Lafarge West Inc.
• To: DMG
• Type & Sequence: AM2
• Media Type: D
• Archive: No

- 3 -
14. Corresnondencelntormation:
APPLICANTf01'IItATOR (name, address, and phone ofname to be used on permrt)
Contact's Name: o++ 1~ < II Title: c~tnrl ~~1C~(1_l51_;

Compa~Name: ~ t^G ~(~p~.3~-, F -~-Y-~L
StreeUP.O. Box: I `'4flO la `~ ~ {~V~21')Clt° P.O. Box:

State: W IOQ~2~ Zip Code: C.~~I
TelephoceNumber: (3~y )- 105- H33b
Fax Number: (~3 ) - b 5 7 - 41.03`1

PERMITTING CONTACT (ff different fram applicant/operator above)
Contact's Nmme: Tide:

Cmm~anv Name:
StreeVP.O. Box: _ _ _ __ P.O. Box:
City:
Stale:
Telephone Number: ( ) -
Fax Number: ( ) -
Contact's Name:
Company Name:
StreeUP.O. Box:
City:
State:
Telephone Number:
Fax Number:
Agency:
Street:
City: VJe-st~~~
State:
Telephone Number: (.~~] - _
CC: STATE OR FEDERAL LANDOWNER (if auk]
Agency:
Street:
City:
State:
Telephone Number. ( ~ - ,
Zip Code:
Title: ~t 1(y ~`l ~P~' C~-~C s-Ci
Zip Code: bOLG I

Code: U~~.~
Zip Code:
( 30~ ~- ioS`1- X33(0
r ~ 3 ) - b5~1- ~o3~j