2004-12-15_REVISION - M1978080

• Permit No: M1978080
• IBM Index Class Name: Revision
• Doc Date: 12/15/2004
• Doc Name: Revised Application
• From: Lincoln County
• To: DMG
• Type & Sequence: AM1
• Media Type: D
• Archive: No

-3-
14. Corresooodence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on pemuq
Contact's Name: Don Blake
Company Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Number:
Contact's Name:
INSPECTION CONTACT
Comparty Name:
Street/P.O. Box:
City:
State:
Telephone Number: ( 1-
Fax Number: ( ) -
Lincoln Coun
Title: Land Use Adm.
103 3rd Ave P.O.Box: 39
Zip Code:
( 719 )- 743-
( 719 1- 743_
(if different from applicanUoperatorabcve)
Contact's Name: Don Blake Title: rand rtGP Aflm-
CompatryName: Lincoln County
StreeUP.O. Box: 10 3 3rd Ave P.O. Box: 3 9
City: Hun n
State: Co . Zip Code: R Og~7,
Telephone Number: ( 719 )- 7 4 3- 2 3 3 7
Fax Number: ( 7t 9 )- ~4~_~at F
CC: STATE OR FEDERAL LANDOWNER (if an
Agency:
Street:
City:
Slate:
Telephone Number
CC: STATE OR FEDERAL LANDOWNER (if an
Agency:
Street:
cirv:
State:
P.O. Box:
Zip Code:
Zip Code:
Zip Code:
Telephone Number: ( ) -