PERMFILE100233

• Permit No: M2005065
• IBM Index Class Name: Permit File
• Doc Date: 9/6/2005
• Doc Name: Reclamation Permit Application Form
• From: Jack Clark Jr.
• To: DMG
• Media Type: D
• Archive: No

-3-
14. rorreapondence Information:
pnPLIC_pNT/OPERATOR (name, address, and phone of name to be used on permit)
Contact's Name: Jack^Clark J~ Title:, ni•nar
. ,
Company Neme:'
StreeUP.O. Box: P.O. Box: rr a 7
City: aitcerton
State: Colorado Zip Code: a t 4 a a
Tel hone Number. 9 7 0 ' °' ~ ~ "' °
Fax Number: ( 1-
PERMITTING CONTACT (if di&erent from applicanUoperator above)
Comact'sName: Crar~aa P_ nnnrhak Title: Geological Consultant
Company Name:
9tteeUP.O. Box: 15 2 9~ s n ~n u d P.O. Box:
City: Montrose
Stagy: Colorado 2ipCode:81401
TelephoncNumber: f_g~n ~- 249-2081 970-249-4434
Fax Number. ( q7n ~- 249_2(181
INSPECTION CONTACT
Contact's Name:
Company Name:
StreeUP,O, Box:
City:
Stan:
Telephone Number:
Fex Number:
Jack Clark, Jr. Tide: Owner
P.O. Box:
Zip Code:
CC: S'i'ATE ORFEDRRpT T pNilnW**cR (~~
P!BmcY:
Street:
City:
Stste: Zip Code:
Telephone Number: ( )
CC: STATE OR F E pt r pNnnwim_~Gg~
Agency:
Street:
aty:
state:
zip cede:
Telephone Number; ( ) _