PERMFILE51048

• 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

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10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: u u S E"1° ~ F_ tv~ S 7 N o F 1`
Company Name : Gu ,F' S T N J F' ~ ~/-) ~ YV1
Street: ~ ~ ~ ~ p 3
c; ty: Gu lip ~,-Ify S
State: C ,~L o Zip Code: ~f ble S~1
Area Code: 3 d,; Telephone: -5(.~ 7 -SS"G /
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: ~` _ ~ _,~; ~ 4~y ~-
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 AgricultureiGA)
land use ^ Rangeland(RL) ^ 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) C 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-c~hed Exhibits A-G are true and correct (must be sign~ed/~by applicant/operator).
Date: V ~~ L ~ ~ ~Z, ~(/,~ ~ BY: ~~~, "~%l~G._.~~ - -
O.~P~
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