REV102335

• Permit No: M1984041
• IBM Index Class Name: Revision
• Doc Name: AMENDED REGULAR 112 PERMIT APPLICATION FORM
• Type & Sequence: AM2
• Media Type: D
• Archive: No

10.

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Correspondance Information
APPLICANT/OPERATOR (name; address; and phone of name to be used on permit)
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Individual's Name: J~R~c .•r.E Fir,~..+h~- °^R"OFT'r'= Z"C"'~"`~~'
Company Name:
Street:
City
State:
Area Code:
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: .1 crr~~c=`~,.~.a
Company Name: JCILC,..7•~' ~~,~,:v,~;a--: /-1--,T:~:.,~•-,, ~ .mac.
Street: ~.O:~a7o I~-'i(3
City: C-r r.~r~i;ooa SOS:,.-~y} Go iv
State: ~'o ~ Zip Code: SIG~OZ,
Area Cade: ~y o'~ Telephone: ~f c~5 S Z~j~a
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City: _
State:
Area Code:
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O 'to •S .Z _ C/I.M•tf»~s M.~. P. (s ~a~. / G 3 d
Go ~.enh-no Zip Code: b I G ~ ~ .
30 ~, Telephone: 3'zra- ro Sa
Telephone:
Zip Code:
11. Primary future 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>Fesources(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 ~ knowledge; all the information presented on this application form and
the attached Exhibits A-P are true and correct (must signed by applic nt/o era tor).
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