2009-09-30_REVISION - M1996050

• Permit No: M1996050
• IBM Index Class Name: REVISION
• Doc Date: 9/30/2009
• Doc Name: Submittal
• From: Forrest Leaf, P.E.
• To: DRMS
• Type & Sequence: AM1
• Media Type: D
• Archive: No

-2-
11. Correspondence Information:
APPLICANT/OPERATOR (name, address, and
Contact's Name: C ,,I L
of name to be used on permit)
Title:
Company Name: L GCr, n, S?, &A T Cr*
Street/P.O. Box: Tc -13 c k ) a P.O. Box: 1 ?S
City: 3
State: r) Zip Code: O IZ Z
Telephone Number:

Fax Number: ( -
PERMITTING CONTACT
' (if differe t from applicant/operator above)
V
N
Contact
s Name: -
- Title:
Company Name:
Street/P.O. Box:
City:
State:
Telephone Number:
Fax Number:
INSPECTION CONTACT

Contact's Name:
Company Name
Street/P.O. Box:
City:
State:
P.O. Box: JOE-
Zip Code: XS0
( S Z ? ) _ 5;-Z- Z- OY6 -7
Title:
. P.O. Box: O
Zip Code:
Telephone Number: 7-7 -7 Z
Fax Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State: Zip Code:
Telephone Number: ( ) -