2007-09-17_REVISION - M2000030

• Permit No: M2000030
• IBM Index Class Name: Revision
• Doc Date: 9/17/2007
• Doc Name: Reclamation permit application form
• From: Elam Construction, Inc.
• To: DRMS
• Type & Sequence: AM1
• Media Type: D
• Archive: No

'3-
11. Carresnondettce Information:
APPLICANT/OPERATOR (name, addross, and phone of nartre to be used on permit)
Contact's Natter; FI;~UIti Elan Title: P[L ~ltjatt
Company Name: ~~C~^~ir^ ~•
StreeUP.0. Box: 556 SFn ttl,arc Atm. P.O. Dox:

Cay: t~-atd ,h~tctim
State: OJ Zip Code: 81501
TelephoneNtunber: ( 970 )- 71+2-5370
Fax A`tunber: 970 ~ - 2k5-7716
(
_
PERMITTING CONTACT (if different from applicantlaperator above)
Contact's Name: I~tt C~ Title: C0[lALlt2flt ~ ~t
Company Name:
Sttcet/P.O. Box: 15 W. Mill Street, Ste. 214 P.O. Box: 1951
city: )$VF'I22[I
State: OJ 'Lip Code: 81]22
'Telephone Ntmtber. f 970 ) - 759-54(23
Fax Ntmtbcr: f 970 ) - 884-5062
INSPEC'I'lON CONTACT
Contact's Nattte: Gavle L. Lit Title: ~ 'tS'
Cotnpany Name: I.711M Cmstnletial 7110.

StreeUP.0. Box: 556 Stn tt}.~rc AVe. P.O. Box:
City: (~7C1 .Jt17Ct1Q11
State: OJ Z.ip Code: 81501

Telephone Number. ( 1-

Fax Ntmtber. ( ) -
CC: STATE, OR FEDERAL LANDOWNER fifanyl
Agrncy:

Street:
City: .« ~- ~_
~~
State: _ Z.ip Cade:
_ _
Trlepbone Number: ( ~ -

CC S'fATF OR FEDERAL LANUOWNFR (ifanv)
Agemy:

Street:
City: _
___
State: ~- ~~. 'Lip Code: _____T --
"Felephone Number. ( ~ - _ __ ____. _