PERMFILE49390

• Permit No: M1987166
• IBM Index Class Name: Permit File
• Doc Date: 10/21/1987
• Doc Name: LIMITED IMPACT OPERATION 110 APPLICATION FORM
• Section_Exhibit Name: Application Form
• Media Type: D
• Archive: No

-2-
10. Correspondance Information

APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: ~ t~SE-y' ~ ~ WfiST1~/D`~
Company Name: l.u F' S T N~ fi~ ~'A. p m
Street: ~ ~ ~ ~ p 3
city : Gu J/~ ~rl ty S"
State: C [~L o Zip Code: ~6GS~/
Area Code: 3 y3 Telephone: ~!~ ~ -SS'G /
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: •` _ ~ _ r _~
1 ,
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
11. Primary future ~ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use ^ RangelandfRL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS)^ Recreation(RC) ^ Industrial/Commercial(IC)
^ Developed Water Resources(WR) ^ Solid Waste Disposal(WD)
12. Primary present ~ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use ^ Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS) ^ Recreation(RC) ^ Industrial/Commercial(IC)
^ Developed Water Resources(WR)
To the best of my knowledge, all the information presented on this application form and
the atta-ct-hed Exhibits A-G are true and correct (must be sign~ed/~by applicant/operator).
Date: V U L ~ ~ ~. ~ ~~ ~ BY: ~i,i'~%//G~' ,2r~ - - - -
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