2005-04-06_REVISION - M1987097

• Permit No: M1987097
• IBM Index Class Name: Revision
• Doc Date: 4/6/2005
• Doc Name: Construction Materials Regular ‎(112)‎ Opertion Reclamation Permit Application Form
• From: Conejos County
• To: DMG
• Type & Sequence: CN1
• Media Type: D
• Archive: No

3 -
14. Corrctnondence Information:
APPLICANThDPBRATOR ( address, and phone of'name to be used on peamit) 22
Contact's Name: ~ ~ ~ CEPS Title:~g V ~[~ /„~`
ComnanvName: i.~ldE4~5 _OulL~v
Stteet/P.O.Box: b~Ort2'~tl 'QD /.~ P.O.Box: /~7
cay: ~vnt~i~5//
state: ~~/d!'G~!o Z~Code: ~l( ~-~
Telephone Number: L 7/Q ) - ~~~- S`1'7 ~
Fax Number: (]l ~{ 1- ~Zb" $~i~i(e ~
PERMITTLNG CONTACT (ff d `~- t from applicanUopetatorsbove)
CoufacPs Name: r ,Ct /nr Tffie:
Company Name:
StreetlP.O. Box: P.O. Box:
City:
Stale:
Telephone Nmmber. ( ) -
Fax Number: [ 1-
INSPECTIONCONTACT
Contacts Nmme: ~iuG
Company Name:
StreetlP.O. Box:
City:
State:
Telephone Nmmber: ( ) -
Fax Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any]
Agency:
Street:
City:
State:
Telephone Ntmmber: ( 1-
CC: STATE OR FIDERAL LANDOWNER fif ~
Agency:
Street:
City:
State:
Telephone Number.
Code:
P.O. Box:

Zip Code:
Zip Code: