REV95789

• Permit No: M1987038
• IBM Index Class Name: Revision
• Doc Date: 11/1/1993
• Doc Name: REGULAR OPERATION 112 RECLAMATION PERMIT APPLICATION FORM
• Type & Sequence: AM2
• Media Type: D
• Archive: No

-z-
9
Correspondence Information:
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code: ~j D ~ Telephone:
PERMITTING CONTACT (if different from applicant/operator above)
INSPECTION CONTACT
Individual's Name
Company Name:
Street:
City:
State:
Area Code:
Z1p Code:
Telephone:
Dori CosNF'u
CC: STATE OR FEDERAL LANDOWNER (if anv)
Agency:
Street:
Cfty:
State:
Area Code: Telephone:
CC: STATE OR FEDERAL LANDOWNER (if anv)
Agency:
Street:
City:
State: Zip Code:
Area Code: Telephone:
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Zip Code:
~~34 - a s33
3 D 3 Telephone: ~Q - Q S 3~