2003-10-29_REVISION - M1987092

• Permit No: M1987092
• IBM Index Class Name: Revision
• Doc Date: 10/29/2003
• Doc Name: Amendment Application
• From: Jordan C. and Jone L. Burdick
• To: DMG
• Type & Sequence: AM1
• Media Type: D
• Archive: No

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Fax Number: ( )-
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Correaoondence Infoxmatio~~ p"' °"""'u° f11/ Giy~~
APPLICANT/OPERAT Gy """'' -
ContacPs Name:
~, ~P~Y Name:
stt~erm.o. sox:
city: r/.e~
State: ~FJ /..o~j_~' D
Contacts Name:
Compaq Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Ntmiber:
INSPECTION CONTACT
Conna:Ps Name:
Company Name:
Street/P.O. Box:
City:
state:
Zip Code:
Title: t^~ u,~!.l
P.O.Box: ~~ [rte
zip Code: /~" U c7 7 %J
Telephone Number: (~~0 3 1- ~ a> ~ - /r `~y~
Paz Number. ( 1-
CC: STATE ORFIDERAL LANDOWNER (if an}~
Agency: ~~i~~~~
Street:
c,>v
(if different from applics~/operaror above)
Title:
P.O. Box:
( 1-
( 1-
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state: zip Code:
Telephone Number: L l -
CC: STATE OR FIDERAL LANDOWNER (if anyl
Agency: /YL_.Gi1irO
Street
City:
State: Zip Code:
Telephone Number: ( l -
OR ( > and phone o name to be used on petmd)
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