2009-03-13_REVISION - M1995063

• Permit No: M1995063
• IBM Index Class Name: REVISION
• Doc Date: 3/13/2009
• Doc Name: Conversion Application
• From: Logan County
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

-3-
11. Correspondence Information:
AM lCANT nPERA`F R (name, address. arf ne of name to be used on permit)
Contact's Name: C S C.J\J` J V- Title:
Company Name:
Street/P.O. Box: L-D
P.O. Box:
City: C --C , ACA
State: _ Q? Zip Code:
Telephone Number: ( (10 - -5-) ZZ :19,- a -__-
Fax Number: (ck- - -Z-z- 1
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name: Title: _

Company Name:

Street/P.O..Box: P.O. Box:

City:

State: Zip Code:

Telephone Number: ( ) -
_
Fax Number: ( ) -
-
INSPECTION CONTACT
Contact's Name: Title:

Company Name:

Street/P.O. Box: P.O. Box:

City:

State: Zip Code:

hone Number:
Tele ( ) -
p -
Fax Number: ( ) -

CC_STATF, OR. FEDERAI. I,ANDO iTNFR if an ?3 p
Agency: -- - - -
Street: ........................................._----- ------------ ----------------------------------- -.
C it
State: Zip Code-
Telephone Number: ------------------------------- s - ----- - - - -...-_...-..._..............................._...... ... ---------------------- --------- --
C C : STATE OR FEDERAL
I.A? I)C?1? ti I R cif anvil ? o ? L,
Agency: --------- ----- ---- - ----------------
Street:
._
_
_•______-- -
_--_-_--
_
City: -----------__--------.._____._._._._--_--------_ __--
State: Zip Code:
Telephone _'tti7tber: (_......._ ..............__....-....-_.l - .._..._.........-_...-......------- .------------- ---.---- ----.------..-...__._...-_..........._
.......
__......._......... .......... .........