2005-10-11_REVISION - M1992054

• Permit No: M1992054
• IBM Index Class Name: Revision
• Doc Date: 10/11/2005
• Doc Name: Reclamation Permit Application Form
• From: LBCR LLC
• To: DMG
• Type & Sequence: CN1
• Media Type: D
• Archive: No

-3-
11. Correeoondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on penait)
Contact's Name: To~ ~t<~l~°V` Title: NI3/12ge(-
CompacryName: l~BGQ~ L-LG
Street/P.O. Box: 14-d-0 $I l-.lP_ 7G~AE G+. P.O. Box:
City: BOc-tIC~GIr r
State: trA Zip Code: SD'JO`~
Telephone Number: L 30 3 ) _ $99 - 07 D7
Fax Ntunber: ( ) -
PERMITTING CONTACT (if different~~fr11om applicant/operator above)
Contact's Name: ~3TT ~trVtaL1~V1 Title: (_o~'15U1'~2+~{-
Company Name:
StrceUP.O. Box:
City:
State:
Telephone Number:
Fax Number:
INSPECTION CONTACT
Contact's Name:
Compaq Name:
Strcet/P.O. Box:
P.o. Box: 1951
Zip Code: ~ 1 IZz
( 970 )- 759 - S4ro3
( 970 )_ Sao-5o~02
SZw12 d5 D2/m r ~ I rl~ -~('itte:
P.D. Box:
City:
State:
Telephone Number: ( ) -
FaxNumber: ( ) -
Zip Code:
CC: STATE OR FEDERAL LANDOWNER (if eny]
Agency:
Street:
City:
State:
Telephone Number:
CC: STATE OR FIDERAL LANDOWNER (if any)
Agency:
Strcet:
City:
State:
Zip Code:
Code:
Telephone Number: ((~1-