PERMFILE139105

• Permit No: M1990062
• IBM Index Class Name: Permit File
• Doc Name: LIMITED IMPACT OPERATION 110 2 APPLICATION FORM
• 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: GllpRleS f /(t,c~Z />'o~dFReM~~/
Company Name:
Street:
City:
State:
Area Code:
PERMITTING CONTACT
W~a.tti:uaToxl Caw-JTv
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~O / 47h /~ u mix/ wt
DTs
Co/oRw do Zip Code: go7y3
'~,0 3 Telephone: ~f6 - 3,~ y7
(if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Telephone:
Zip Code:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Telephone:
Zip Code:
11. Primary future Cropland(CR) ~ Pastureland(PL) General Agriculture(GA)
land use - Rangeland(RL) Forestry (F R) - Wildlife Habitat(WL)
(check one): - Residential(RS) i Recreation(RC) _ Industrial/Commercial(IC)
Developed Water ~sources(WR) ~ Solid Waste Disposal(WD)
12. Primary present Cropland(CR) ~ Pastureland(PL) General Agriculture(GA)
land use _ Rangeland(RL) Forestry (F R) i Wildlife Habitat(WL)
(check one): - Residential(RSj " Recreation(RC) - Industrial/Commercial(IC)
i Developed Water R`esources(WR)