2003-07-28_REVISION - M1986076

• Permit No: M1986076
• IBM Index Class Name: Revision
• Doc Date: 7/28/2003
• Doc Name: Submittal
• From: DGMC
• To: DMG
• Type & Sequence: AM3
• Media Type: D
• Archive: No

-2-
" 7. Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: ~'/l71 ~~~~~R Title: O~NrtZYb~`
Company Name: Qfad Wood G'oleh ///)41eS Ca.
streevP.o. Box: o'S~ 9 v.S. Nu...,. G y P.o. sox:
J
city FA,e.~~ e„
State: /y /}~ Zip Code: 87y~~
Telephone Number: (SOS ) - 32.$ ~ ~/OGS~ O r S-OS- 63 ~ ^/~ 7~
Fax Number: (SDS ) - 3c~~o ' ~$5~2
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: ~ ~iti Title:
Company Name:
Street:
City.
State: Zip Code:
Telephone Number: ( _) -
FaxNumber: ( )-
INSPECTION CONTACT
Contact's Name: sA/nC e~S /Qtjed~° Title:
Company Name:
Street.
City
_ State: Zip Code:
Telephone Number: ( )-
Fax Number: ( ) -
CC: STATEORFEDERALLANDOWNER(ifany)
Agency. //
Street:
City.
State:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDO WNER (if anv)
Agency. ~ j/9
Street:
City.
State:
Telephone Number: ( )-
Zip Code:
Zip Code: