PERMFILE126314

• Permit No: M1986140
• IBM Index Class Name: Permit File
• Doc Name: LIMITED IMPACT OPERATION 110 APPLICATION PACKAGE
• Media Type: D
• Archive: No

Y i •

-2
10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: /"lerr~ll Wry a I,7-
Company Name: (~.,;versal P~~fi Sc~.,1 4n~ 6r~„~/3 ~hc
Street: 1557 S, Lngulls
City: Lal~ewoo cl
State: Colorodo Zip Code: ~paa6
Area Code: 303 Telephone: 935- 8"558
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Zip Code:
Telephone:
Sa~~
INSPECTION CONTACT (if different from applicant/operator above)
Individual' s Name:
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
X11. Primary future ^ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
S~.„e !fir land use ^ Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
/,~,_g~5_ofro(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 attached Exhibits A-G are true and correct (mnust be signed /~by applic;~ant/onperna'tor).,~
Date : 0 c7'a b e r 1 , 19 ,S'6 BY : .t.A.~,~.X ~.~,.~YO~j~.~ (~~0,
~ `
i e