2004-11-22_REVISION - M1978266

• Permit No: M1978266
• IBM Index Class Name: Revision
• Doc Date: 11/22/2004
• Doc Name: Conversion Appl
• From: Jackson County
• To: DMG
• Type & Sequence: CN1
• Media Type: D
• Archive: No

3-
14. Corresoondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: Nelson Selcer Title: Supervisor

Company Name: Jade3on Cotmly Road and

Street/P.O. Box: 188 Grant Street P.O. Box: 488
City: WaHat

State: Colorado Zip Code: 80480

Telephone Number. ( 970 1- 723-4481

Fax Number: ( 970 1- 723-8437

PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: Title:

Company Name:

S[reet/P.O. Box: P.O. Box:

City:

State: Zip Code:
Telephone Number
Fax Number:
INSPECTION CONTACT
Contact's Name:
Company Name:
Street/P.O. Box:
City:
State:
Title:
Telephone Number: ( 1-
Fax Number: ( 1-
CC: STATE OR FEDERAL LANDOWNER (if anyZ
Agency:
Street:
City:
Stale:
Telephone Number: ( 1-
CC: STATE OR FEDERAL LANDOWNER (if anyl
Agency:
Street:
Ciry:
Stale:
P.O. Box:
Zip Code:
Zip Code:
Zip Code:
Telephone Number ( 1-