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s-i~l- d ~ <br /> <br />3- <br />M-~~B~--oaf <br />Corteaoondeace faformatba: <br />APPLiCANT/OPERATOR (tutnc, address, end phone of name to Fx uxd on permit) <br />Canteet'a Name: 1~i. ~1-t- QD~~soeti Title: ~-F'2.a=..s~ oe-NT <br />CompaoyName: ~ t-otuaoc~ 1~~h-arc ,'~~~ <br />streetm.o.Bcx: ~-~-~ ~-~,o~~we.~ P.~a-~~o.;at,~, <br />City: u.R-.'~2~>~ t ~~-+~ , <br />Stale: L-~ectZC: r A 7.ip Code: ~ I ~ I <br />'1'ckpttone Numbs: f ~~ O ) - (oL~~ - '~34-?' <br />Fax Nmnber. ! ~-d-O ) • (~ 3~Io <br />T7:jNG CONTACT (ifdi$erent Gom epp(i`c\aatlopaatar~bov~) <br />Contact's Name: ~ot~ _ rSOt~~NA~ Title: ~~SrDFav`1 <br />CompanyNeme; 1"~nr+nktri \~1DL~KTPU'Cl rnRt>c~E- C~~MPAN~ <br />Stred/P.O. E3ox: P.O. Box: '`fb~'i <br />Ciry: '>AH D A <br />State: Ce~~nRAD!? Zip Code: ~1 ~ <br />Tetcplwne Number: ( ~ 1 ~ ) - 5`~ - 113-3 <br />Fax Ntanlxr: ( ~ 9 ) - 5~ - 117j¢ <br />INSPECTION CONTACT <br />Contac's Name: ..,,,,nn ~~e~9 ~p1-.;vwFS`S Tick: Ql?,~t pF>13'C <br />Compsay Namc 111ot~AR.tst '(~o...rp.TA\td Mnae)..E ~OMPAn1~ <br />Street/P.O. Bmt: P.U. Box <br />City: ~.~kl-t DA <br />State: ~sJ~®tz~DO Zip Code: ~\~ t <br />Tetephotte Number: ( ~ ) - '~~~ ' l 1~3 <br />Fax Nranber. ( ~~"19 1- 5~ - 1 1 ~g- <br />CC STATE ORFEDERAt,I.AN(~WNFX(ifatty] A <br />Agency: lw~~s cam' tltt~Ex~1T10N = M ~ ~<\lcri~jY-t <br />Street: ~J2~ w ~r.~1t1 ~P*.N ~1~j1~J' <br />City: Gi/H-.~D R <br />State: ~-~' Q.AOn Zip Code: ~ 1 "LD I <br />Teleplwrre Nwnber: ~') -*'~3~ ~ ~~ 1 <br />CC STATPORFFL)PRAI.LaninnwntFR(U'a~) <br />Agt~y: <br />Street: <br />Cifv: <br />state: <br />Tekphotte Ntrmber: ( ) - <br />zip code: <br />r~ fol <d. <br />?a. ~2r~1S <br />M~r~IP <br />~~ <br />