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3- <br />1 I. Correspondence Information: // <br />APPLICANT/OPERATOR ( address~~nd phone o to be used on permit) /~ ~„n/~'~ ~ ~ Ort- e!K <br />Contact's Name: Ktc C oU•t/l ~/ C. Gr/~~JSSSLn4/ ~,PS Title: ~f~R~i~'//~JAN <br />Company Name: .~fl/t'~ OL(N7't/ ' / <br />Street/P.O. Box: J`D 5 f/~~SON ~-t~l~. P.G. Box: 9~7 <br />City: . cvyv <br />yu ~. <br />ma <br /> <br />State: / <br />y <br />l <br />(_o~~ri~o <br />Zip Code: p^' // <br />O ~'7fP~ <br />Telephone Number: ' / <br />7~ - - ^f <br />~~ ' /fin <br />~7 7.3 <br />Fax Number: p <br />( 7 ~ ~ 1- 'y0 Fi ~ ..~~~J' 7z <br />PERMffTING CONTACT (if diffe ent from applicanUopera <br />-~ tor above) <br />Contact's Name: . <br />ZCh/AF <br />L u~~ Title: <br />Company Name: / , <br />, <br />// <br />~-+~fl~~ G ~U/f/~ ~OI~~ ~ ~/~.Z~C7 ~ <br />StrcetlP.O. Box: /~X9 f~f~z ~G ~ ST. P.O. Box: 9 S~ <br />city: .CL-'~9.l~!/~1L E <br />State: L "~LOR~~D Zip Code: ~~'~f~~ <br />Telephone Number: [ ~O/ ~+ <br />~-dZS7 <br />( ~ ~ ) - BYO F <br />Fax Number: // <br />7/ - '~i~~V - $ /'~7~ <br />INSPECTION CONTACT <br />~ /~ ~ !!JJ~~ ,'/ <br />G <br />E <br />'~ <br />B~ <br />' <br />Contact's Na>ce: L7 Title: E.( I <br />/ <br />f <br />G TO <br />G R~ <br />Company Name: <br /> <br />StreeUP.O. Box: <br />~ZG~ I~~ZE~ <br />.ST <br />P.O. Box: /~~j <br />SL- <br />City: L.~ ^l / <br />State: ~~ Lv/ Zip Code: ~(17~~ <br />Telephone Number: ~/~ - ~Y ~'" ~ ZJ'~~ <br />Fax Number: i ~~9~ - ~~6 - 8y'f 9 <br />CC: STATE OR FEDERAL LANDOWNER (if env) <br />Agency. <br />Street: <br />City: <br />State: <br />Telephone Number: ( ~ - _ <br />CC: STATE OR FEDERAL LANDOWNER (if and <br />Agency: <br />Street: <br />City: <br />State: <br />Telephone Number: { ) . <br />Zip Code: <br />Zip Code: <br />