Laserfiche WebLink
<br />-s- <br />city: <br />State: <br />Area Code: <br />ells ~~ E a k <br /> <br />G U ., Zip Code: ~ ~-` y y <br />3 O3 Telephone : ..S ~ Q - .3 SS / <br />(if different from applicant/operator above) <br />Individual's Name: <br />Company Name: Q <br />Street: <br />City: <br />State: <br />Area Code: <br />INSPECTION CONTACT <br />Individual's Name: <br />Company Name <br />Street: <br />City: <br />State: <br />Area Code: <br />Agency: <br />Street: <br />City: <br />State: <br />Area Code: <br />Agency: <br />Street: <br />City: <br />State: <br />Area Code: <br />Title: <br />Telephone: ~'~ 5 <br /> <br />,~ C <br />S q vN ~ <br />Telephone: <br />Zip Code: <br />Telephone: <br />Zip Code: <br />Zip Code: <br />Telephone: <br />11. Primary future (Poet-mining) land use (check one): <br />y Cropland(CR) _ Paetureland(PL) General Agriculture(GA) <br />_ Rangeland(RL) _ Forestzx (FR) _ <br />_ Wildlife Aabitat (WL) <br />Residential(RS) Recreation(RC) Industrial/Commercial(IC) <br />Developed Water Resources(WR) _ Solid Waste Dieposal(WD) <br />12. Primary present land use (check one): <br />~ Cropland(CR) _ Pastureland(PL) _ General Agriculture(GA) <br />_ Rangeland (RL) Forestry (FR) Wildlife Habitat (WL) <br />Residential(RS) _ Recreation(RC) _ <br />Industrial/Commercial(IC) <br />_ Developed Water Resources (WR) _ Mining (MN) <br />:3. If this operation will use designated chemicals, or will result, or presently has <br />acid mine drainage - you cannot use this application form. You must submit a either <br />a 110d or 112d application form for Designated Mining Operations. In either case, <br />you must list any acidic or toxic-forming materials, exposed or disturbed as a <br />result of the mining operation, and whether the operation will result in or <br />presently has acid mine drainage : A/ ~~ :...~ p ~ ~ ~ ~ N / o .,, ~ /.. ,a ti .~~ <br />Description of Conversion: <br />If you are converting an existing operation, provide a brief narrative describing the <br />proposed change(s). <br />MdD6 6 EXhi lte: <br />Submit two (2) cosip ete, unbound copies of the following application exhibits: <br />6.3.1 EXHIBIT A - Legal Description and Location Map <br />6.3.2 EXHIBIT 8 - Site Description <br />