2006-09-11_REVISION - M1984043

• Permit No: M1984043
• IBM Index Class Name: Revision
• Doc Date: 9/11/2006
• Doc Name: 112c application
• From: Pelino Inc
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

-3-
1 L Correaoondeoce Informatloe:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)

Contact's Name: Scott Pelino pres.
Title:
ComparryName: Pelino, Inc.
StreeUP.0. Box: 33551 CR 361 P.o. Box: 5049
Buena Vista
Ciry:
State: Colorado Zip Code: 81211
Telephone Number: { 719 ) - 395-2093
Fax Number: { ~ - same
PERMITTMG CONTACT (if different from applicanUopemtor above)
Contact's Name: Jon Roorda T;Ue: Iand Surveyor
Company Name: Arkansas Valley Survevir>A
SveeUP.0. Box: 28350 CR 317 Unit 9 P O Box: 1111
Ciry: Buena Vista

State: Colorado Zip Code: 81211
Telephone Number: ( 719 )• 395-3185
Fax Number: ( ) • same
' Same as Applicant~Operator
Contact
s Name: Title:
Compatry Name:
StreeVP.0. Box: P.O. Box:
City:
State: Zip Code:
Telephone Number: ( ) -
Fax Number: { ) _
CC' STATE OR FEDERAL L ANDOWNER (if any)
Agency:
Street:
City:
State: Zip Cude:
Telephone Number: ( ) -
CC STATE OR FEDERAL L ANDO WNER !if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( ) -