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i <br />3- <br />11. Correstwndence Tnformatlon: <br />APPLICANT/OPERATOR (name, address, and phone of name to be used on permit} <br />Contact's Name: Va-n+eS S /y, ~t.c'r Title: i~r F S i d~F s~ <br />Company Name: ~u i ~ ~d r S Ar+~ A LY ~ P ~rr~~. c <br />Street/P.O. Box: / ~S` ~~. ~r11 / ~Zr f~ Yom. P.O. Box: <br />City: __~ <br />-{-p.--~ /L'O rai Gt ~t <br /> <br />State: <br />~r, ~F <br />Zip Code: D D 70 <br />Telephone Number. 0770 1- ~fc~ ~ (l 3 3 <br /> <br />Fax Number: ( ) - <br />PERMITTING CONTACT (if different Gum applicandoperator above) <br />Contact's Name: S'f7-~+r ~ Title: <br />Company Name: <br /> <br />Street/A.O. Box: A.O. Box: <br />City: <br />State: <br />Telephone Number: <br />Fax Number. <br />INSPECTION CONTACT <br />Contact's Name: <br />Zip Code: <br />S7A/h~ Title: <br />Company Name: <br />Street/P.O. Box: <br />City: <br />State: <br />Telephone Number: ( ) - _ <br />Faz Number: ( 1- <br />CC STATE OR FEDERAL LANDOWNER /if anyj <br />Agency: <br />Street: <br />City: <br />State: <br />Telephone Number: / ) -_ <br />CC: STATE OR FEDERAL LANDOWNER (if anvl <br />Agency: <br />Street: <br />City: <br />State: <br />Zip Code: <br />P.0. Box: <br />Zip Code: <br />Zip Code: <br />Telephone Number <br />