2012-06-25_REVISION - M2006010

• Permit No: M2006010
• IBM Index Class Name: REVISION
• Doc Date: 6/25/2012
• Doc Name: New Conversion Application
• From: Las Animas County
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

1 1. Correspondence Information
APPLICANT /OPERATOR (name, address, and phone of name to he used on permit)
Contact's Name Phil Dorenkamp hoe R8,13 Sup
Compare} Name Las Animas County
StrectiP () Box 2000 N. Linden Ave P () Ilox
Can Trinidad
State Colorado zip Code 81082
Telephone Number ( 719 ) - 846 - 2931
Fax Number ( 719 ) -
846 - 0434
PERMITTING CONTACT (if different from applicant/operator above)
Contact's Name same Lytle
Company Name
Street/P O. Box P 0 Box
City
State: Zip Code -
Telephone Number. ( ) -
Fax Number ( ) -
INSPECTION CONTACT
Contact's Name sam Title
Company Name.
Street/P O Box P O Box:
City.
State Zip Code.
Telephone Number ( l -
Fax Number ( ) -
CC STATE OR FEDERAL, LANDOWNER (dam')
Agency
Street
City
State
Telephone Number
n/a
CC S' I 1' E()RI1DFRAI,1.ANI)OWNFF,12 (if any )
Agency n;
Cit\
State
telephone Number 1-
lip Code
' Ci,df.