2010-10-19_REVISION - M1983187

• Permit No: M1983187
• IBM Index Class Name: REVISION
• Doc Date: 10/19/2010
• Doc Name: AM-1 Application and Fee
• From: Logan County
• To: DRMS
• Type & Sequence: AM1
• Email Name: AJW
• Media Type: D
• Archive: No

70067 02 9/29/2010 03:20 PM B. 00988 P: 831 DOCUMENT
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Pamela M. Schneider Clerk & ill r1kND?IJ?4?4C4?+??6aIJA(' W 140.14k111 11111 co
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1 1. Correspondence Information:
APPLICANT/OPERATOR (name, dress, an p one of name to be used on permit) 1
?drG\ nO
X-?? ^n "o
Contact's Name: ff
Title:
Company Name:
Street/P.O. Box: _ P.O. Box: _
City:
1
S raja ) 2) ol-61
Zip Code:
tate:
Telephone Number: (
( -l ) - J Z- -Z - -- % \ -
Fax Number: ( ) S Zz- - 4 L) U -

PERMITTING CONTACT (if differe t from applicant/operator above)
Contact's Name: 11.9 c ` S V --'n.? \--,, `^ Title:
Company Name: 5
Street/P.O. Box:
City:
State:
Telephone Number: ( ) -
Fax Number: ( ) -
INSPECTION CONTACT p
Contact's Name: S ` Q-`^? Title:
Company Name: ????? a5 G?? a ?Z. -
Street/P.O. Box: P.O. Box: _
City:
State:
Zip Code:
Telephone Number: ( ) -
Fax Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if any)
Agency:
Street:
City:
State:
Zip Code:
Telephone Number: ( ) -
CC: STATE OR FEDERAL LANDOWNER (if anv)
Agency: W--o Ae-
Street:
City:
State:
Zip Code:
P.O. Box:
Zip Code:
Telephone Number: ( )