PERMFILE130196

• Permit No: M1976051
• IBM Index Class Name: Permit File
• Doc Date: 5/16/1989
• Doc Name: REGULAR 112 PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

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10. Correspondance Information
APPLICANT/OPERATOR (name, address, and
Individual's Name: ~,,~kzls
Company Name : ~ ~, ~ ke Is
Street: 4 ~~30
City: 5+~~, .,~ ~
State : to
Area Code:
PERMITTING CONTACT
Individual's Name: G=~~~ /~. ~.,~~~5
Company Name: 5 ~--N ~ s s /a ho~~
Street:
City:
State:
Area Code:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
phone of name to be used on permit)
(mnS ~ /-JC ~~~ZM w•L
~L 1L5
oa 4- 5'~'r ~ S
Zip Code: fso ~~ ~~
Telephone:
Zip 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) Recreation(RC) Industrial/Comnercial(IC)
Developed Water l~esources(WR) _ Solid Waste Disposal(WD)
12. Primary present _ Cropland(CR) _ Pastureland(PL1 _ General Agriculture(GA)
land use Rangeland(RL) _ Forestry(FR) _ Wildlife Habitat(WL)
(check one): - Residential(RS) Recreation(RC) _ Industrial/Comnercial(IC)
Developed Water TZ-esources(WR)
To the best of my knowledge, all the information presented on this application form and
the attached Exhibits A-P are true and correct (must be signed by ap nt/operator).
Date: ~~~~ SS By:
47rcS ~ (~w.i-
it e
3a3 Telephone: 8~9 - Lo-r~
(if different from applicant/operator above)
Zip Code: