2004-07-13_REVISION - M1994096

• Permit No: M1994096
• IBM Index Class Name: Revision
• Doc Date: 7/13/2004
• Doc Name: Fax of Conversion Material
• From: Randolph W. Starr P.C.
• To: DMG
• Type & Sequence: CN1
• Media Type: D
• Archive: No

Jul 13 04 10:19a
Rantlolph tJ. Starr 970 669 3841 p.4
11' 3
14. Correaooodence Information:
APPLICANTlOPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: t..J~r _ -: ce h .Title: !-
Company Name: J, ~ c. / . - .. _,.:%'. _~ .1" . ~ ; : ~
StreetlP.O. Box: , .• /. ,' ~ti:.~~ I' c ~= °-7 P.O. Box:
,: .. _ ..
City: '.,;-..( ~L %t"'; .:
State: ~/ L ' , Zip Code:
Telephone Number: (• r 1- ` % /c • .-~ -
Fax Number. L 1-
PERMIT7TrIGCONTACT (if different from applieanUop~attx above)
CoateM's Name: 5A-M~ Title: _
Compmmy Name:
SneeUP.0. Box: P.O. Box:
City.
Stater Zip Code:
Telephone Number. ( 1-
FaxNumbu: ( 1-
INSPECTION CONTACT
Conract'sNattte: ~P/.'.~ Title:
Compaoy Name:
StreetlP.D. Box: P.O. Box:
City: ,
State: Zip Code:
Telepttoae,Number. ( )-

FaxNumber. { )_
CC STATE ORFEDE>}A i LATIDOWNER(Lfsay)
Agency: _ ~1IDr! .~_
Sweet:
City:,

State: Zip Codc:
Telephone Number: I 1-

CC~ STATE OR FEDERA L LANDOWNER (if anv)

Agency: /1E;'t<{ ~-
Strcet:
City:
State: Zip Code:
Telephone Number. ( ) -
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/ jl
1 r-,
<:
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