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- - - -- nu. aac LVCJJ <br /> Attachment C <br /> REQU28T FOR AVS RECONXENDATION <br /> Requests should be nailed to: Mr. Keith Harrison <br /> AVS Recommendation Coordinator <br /> Office of Surface Mining <br /> 2679 Regency Road <br /> Lexington, Kentucky 40SOS-4225 <br /> Requests should be FAZED to: (606) 233-2699 <br /> Attention: Keith Harrison <br /> Requests that are phone in: (606) 233-2861 (direct) <br /> 1-SOO-643-9748 <br /> Keith Harrison <br /> 1. Requesting Office: /rh /3 rr Date: 9 a q <br /> Name: en o y✓�r�r� �r .-� A-, Phone No. s3� , <br /> �'� S G7 <br /> 1q FAY No. : 3" r a_S/c6 <br /> Contact Person: <br /> Type Contract: Emergency Non-Emergency �^ <br /> 2. Contractor Information: <br /> Naas: /.l t-e-'eA s1-1:2 7'c.� -�h�-- <br /> Address: // 7.3 0 .sue>orIh G I Vej r—� <br /> .f3 Doerr,z c/d G el A d e r <br /> Phone No. : yjg�4-l F-0"9 <br /> Employee I.D. : 6'�-0 9a.3A.s"g <br /> Subcontractor Information: <br /> Name: <br /> Address: <br /> Phone: <br /> SON or TIN: <br /> Inspector Information: it not part of the above companies. <br /> Name: <br /> Address: <br /> Phones. <br /> SSN or TIN: <br /> For emergency recommendations, the Ownership and Control Data <br /> Certification information should be included with the request. <br />