2007-06-28_REVISION - M2004001

• Permit No: M2004001
• IBM Index Class Name: Revision
• Doc Date: 6/28/2007
• Doc Name: Submittal
• From: Lincoln County
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

3-
11. Carreatwndenee Intarttmtlon:
APPLICANTIOPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: Kenneth Morrison Tidc:ls~I~1 Ij~~adm;n•
CompanyNamc: Lincoln County
StreeUP.O. Box: 1 O 9 4 r A A V Pr1ll P P.O. Box: 4 9
City: Hugo

Stan: r~A 1 n ram Zip Code: R ll R ~ 1
Telephone Number. ( 719 } - 7 4 3 -~ ~ ~ 7
Fax Number. { 719 1- 743-2815

PARMfCT1NG CON3'ACI ' (iftlilferem from applicanttoperator above)
Contact's Nate: Title:
Company Name;
StteeNP.O. Box: P.O. Box:
City:
State: Zip Code:
Teloplane Number: { ) -
Fax Nwnber: ( ~ -
INSPECTION CONTACT
Cotttact'sNat~: xPruieth~lnrris~n. Titte: baa.d Ilse lldmiri
CompanyNatne: Lincoln County
Slreot/P.O.Doz: 103 3rd Avenue P.O.Box: 3S
City: Hugo

State: Colorado Z.{pCode: 80821
TetephoneNumber: (719 j- 743-2337
FaxNurtdrer, i 719 }_ 743-2815
CC: STAT'P.ORPEDERA LLANDOWNER(ifany,)
A8enc3'-
Street:
City;
State:
Z.ip Code:
Telephone Number: ( 1- __,__
CC; STATE OR FEDERAL LANDOWNER (if soul
Agency:
Street.
City:
State:
Zip Coda:
'telephou Number: ( 1-