PERMFILE111769

• Permit No: M2004067
• IBM Index Class Name: Permit File
• Doc Date: 11/21/2005
• Doc Name: Exhibit 201-202
• From: City of Black Hawk
• To: DMG
• Media Type: D
• Archive: No

3-
11. Correspondence Information:
APPLICA_N7YO~ATdR (name, address, and phone ofname to be used on permit}
ContacPs Name:
Compaq Nerve:
Street/P.0. Box:
City:
State:
Telephone Number. ( 1-
FaxNumber: ( 1-
~IITTING CONTACT (if different from applicant/operator above)
Contacra Name:
Company Name:
StreeUP.O. Box:
City:
State:
Telephone Number ( 1- _
Fax Number. L _]-____
• INS PECTION CONTACT
ContacPs Name:
Company Name:
Street/P.O. Hox:
Cily
State:
Telephone Number; L, ) - __-___
Fax Number: ( l - _
Ct'- STATE R~LANDOWNER lif anvl
Agency:
Sttcet:
City:
State:
Telephone Number: ( 1-
C6 STATE OR FIDERAL LANDOWNER (if ~

Age>Ky:
Street:
Ciry:
Stets:
Telephone Number: ( ~ -
Title
P-O. Box
Zip Code:
Title:
P.O. Box:
Zip Code:
Title; _
P.O. Box:
Zip Cade:
Zip Code:
Code;