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2005-11-21_REVISION - M1992045 (9)
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2005-11-21_REVISION - M1992045 (9)
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Last modified
6/15/2021 2:58:18 PM
Creation date
11/21/2007 11:35:53 PM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
M1992045
IBM Index Class Name
REVISION
Doc Date
11/21/2005
Doc Name
Reclamation Permit Application Package
From
James VanElla
To
DMG
Type & Sequence
AM1
Media Type
D
Archive
No
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<br />Ir <br />-z- <br />Q f'nrrwnnrnndrnrn infnrmntinn~ <br />APPi.i['ANT/APF.RATAR (name, address, and~,h,one of name to be used on permit): <br />Contact's Name: ~ ~ ~/ ~ E'vO9 Title: C~'-LCrau/t~ <br />Company Name: <br />Street: ~~~ .L~l/L'F a~00,s~P>'~S~ A.~'`G" P.O.Box: <br />city: 1•'~~~1L1" D L .o ~1d..7~ <br />state: ~~ ~ j~~ A zip Code: '~ 703 <br />Telephone Number: ~0~(00 ~ _ ~lovF'~OjiU <br />.mac Number: (rte low i . ~~~ ~ ~6.2 ~t~ . <br />PF.RMi777-T(: [ nNTA('T (if different from applicanUoperator above): <br />Contact's Name: Title: <br />Company Name: <br />Street: PO. Box: <br />rnn,~ <br />State: Zip Code: <br /> <br />hone Number: ~ ~ - <br />Tele <br />p <br />Fax Number: ( ~ - <br />(1NTAf"R <br />O <br />[ <br />iNCPF.f'TI <br />N <br />' <br />Contact's Name: Title: <br /> <br />Company Name: <br />Street: P.O. Box: <br />City: <br /> <br />State: Zip Code: <br />Telephone Number: ( ~ - <br />Fax Number: ( ~ - <br />['['c STATF OR Fp'.nFRAi.i.ANDAWNF.R (jfany): <br />Agency: <br />Street: <br />City: <br />State: <br />Telephone Number: ~ t - <br />(`('~ CTATF. AR Ffi.l)F.RAi. i.ANli(iWNF.R (jf any): <br />Agency: <br />Street: <br />City: <br />State: Zip Code: <br />Telephone Number: j ~ - <br />Zip Code: <br /> <br />
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