PERMFILE135839

• Permit No: M1986148
• IBM Index Class Name: Permit File
• Doc Date: 10/17/1986
• Doc Name: LIMITED IMPACT OPERATION 110 APPLICATION FORM
• Media Type: D
• Archive: No

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10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone~/of
Individual's Name: ~~1~//7 (K.
Company Name: fjloG,Se,~~,~'~~
Street: / S' S !.(
c;ty: a o
State: ~~

to be used o,n permit)
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Zip Code: ~/30 ~
Area Code: 3F3 Telephone: Z~I'7~ f~/D ~
PERMITTING CONTACT (if different from applicant/operator above) ~
Individual's Name:
Company Name:
Street:
City:
State:
Area Code: Telephone:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street: i
City: j
State: Zip Code:
Area Code: Telephone:
11. Primary future
land use
(check ane):
12. Primary present
land use
(check one):
Cropland(CR) ^ Pastureland(PL)
^ Rangeland(RL) ^ Forestry(FR)
^ Residential(RS)^ Recreation(RC)
^ Developed Water Resources(WR)
^ Cropland(CR) C~Pastureland(PL)
^ Rangeland(RL) ^ Forestry(FR)
^ Residential(RS) ^ Recreation(RC)
^ Developed Water Resources(WR)
^ General Agriculture(GA)
^ Wildlif Habitat(WL)
^ Industr al/Commercial(IC)
Q Solid W ste Disposal{WD)
^ General Agriculture(GA)
^ Wildlif Habitat(WL)
^ Industr al/Commercial(IC)
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 appli a9,t/operator).
Date: /y/ / ~~60 BY~ ~J.(~~(/CPcG JL~ _
Zip Code: ~~
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