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• ..' <br />-z- <br />:i. Address and Phone iJumoer of ~ /3p~ /~~sZ~~~ <br />Local Offices ~i~1~-5.~5~ /~~~~~ Co~a_ 9023 <br />4. Address and ?none Number of <br />General Offices ~el1 _ ~ ~,7 <br />5. tJame and Phone tJumoer of Person / // ~ <br />Staff iHemoers Should Contact ,~Gvvy _L,~har~~~/~ ~Y~S6S"7 <br />ti. Owner(s) of Record of Affected Lana ~ ~ / / / ~ <br />(surface area) (If more than L, list below) Y~-y G, (_ r4Yt/t J~ <br />J ~e ~.-,'~,'~ . L. C~~a ,. <br />~~ e <br />//. <br />7. Owner(s) of Substance to be shined R rvy ,~ , ~ q rT/ e/' <br />(If more than 2, list beloev) , <br />d.. Source of Legal Right-To-Enter 11 ` I,,. ~L <br />(Indicate what type of proof is ~01 C(o-s'c ~ C~P~- ~~ Dr~A o~~+t~ 1 <br />included in E)' -lease, <br />deed, notarized letter et_c•) \ ~X ~~ bl''f /~ <br />9. Type of ~~line and Substance to be hlined l7 <br />(Specify underyround, open pit; / <br />quarry, etc. ~ substance(s) to ©~(jiy p~~t G/~ciUC.•I <br />oe mined) ~J <br />lU. General Location and Elevation ~ mort~, i~ i~rvrrl.. ~~ Eq,r~' <br />(hliles & direction fro~n nearest / <br />tuwn & approximate site elevation) ~~ J7or'r~. ~(~Va /t e~ ,t~(aSS~ <br />11. County pvoora~aru CetA,.Ty T <br />12. Acreaye of ;;rfected Lands <br />(Total surface acreage to b~f_' <br />iociuded in permit) / ~7+s ~j,CTC'S Cf~1 "~'~ <br />I a r <br />i,. tipplication Fee (See applicaole <br />Rule to determine amount) f6 <br />m~ <br />D5 <br />w Ro s ~ s ~kp~1e <br />