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-3- <br />11. Corresaondenc~z Information: <br />APPLICANT/OPERA'TOR (na-m~e, address, and phone of name to be used on permit) <br />Contact's Name: ~L{ '~/~ ~ 1~!~~.f,~ <br />Company Name: <br />Street/P.O. Box: <br />City: L~-P©~r~e.~ ` <br />State: ~~_.~~C j Zip Code: <br />TelephoneNumi~er: ~~.-.(~-Z- ~°d l '~ C~/~~7 - <br />Fax Number: ( ) - <br />PERMITTING CONTACT (if d~iff~erent from applicant/operator above) <br />Contact's Name: V t Cr ~~~.~ l 5 Title: <br />Company Name: <br />Street/P.O. Box: <br />City: <br />State: <br />Telephone Number: <br />Fax Number: <br />INSPECTION CONTACT <br />Contact's Name: <br />Company Name: <br />Street/P.O. Box: <br />City: <br />State: <br />t <br />P.O. Box: <br />F~'~~ r <br />~...[~-!j~.A,~L~ ~~ Zip Code: <br />L7~.t~ )- 431v~«7~ <br />( )- <br />_ , <br />~ ~ ~` ~{ t Lj G~ p t~t~ Title: <br />P.O. Box: <br />Telephone Numt>er: ~ 1- <br />Fax Number: ( ) - <br />CC: STATE OR FEDERAL LANDOWNER (if anv) <br />Agency: <br />Street: <br />City: <br />State: <br />Zip Code: <br />Telephone Numt~er: ~ ) - <br />CC: STATE OR FED]~RAL LANDOWNER (if anv) <br />Agency: <br />Street: <br />City: <br />State: <br />Zip Code: <br />Zip Code: <br />Telephone Number: ~, ) - <br />