PERMFILE107898

• Permit No: M1987103
• IBM Index Class Name: Permit File
• Doc Name: APPLICATION WORKSHEET CHECKLIST
• 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: B:i,ldre~i ~im~
Company Name: ~• Sime (;ravel Co.
Street: Hax 51
State: Colorado Zip Code: 81648
Area Code:~_ Telephone: [phone]
PERiNITTING CONTACT (if different from applicant/operator above)
Individual's Name: saV.,
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
1NSf'ECTION CONTACT (if different from applicant/operator above)
Individual's Name: satW=
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
11. Primary future ^ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
' land use (~ Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS)p 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 attached Exhibits A-G are true and correct (must be signed by applicant/operator).
~ ,
Date: .r„n„ ~~ ,np~ BY: ~~_.r~ ~n~..~~ ~h~
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