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~/]$ APPLICATION CHECKLIST ~jJ~ ~ <br />LIMITED IMPACT (110) ~• NAME ~~a~/' ~"~~/~ FILE ~ 2b$' <br />SPECIAL 10-DAY (Ill)-_----------------------COMPLETE (,F LEU/ DATE--- y'_y _7 9 -- <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: Z <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address & phone, local / <br />4. Address b phone, general <br />5. Person to contact ,/ <br />6. Surface owners <br />7. Mineral owners <br />8. Source of legal right-to-enter / <br />'/ <br />9. Type of mine/substance / <br />! <br />/ <br />10. General location & elevation ~ <br />11. County / <br />[~ <br />12. Acreage <br />13. Fee <br />14. Present land use / <br />15. Proposed future use <br />16. Signature ~/ <br />Maps and Exhibits <br /> <br />EXHIBIT A - Legal Description / <br />v _ <br />EXHIBIT B - Mining Pian <br />EXHIBIT C - Map ~~ <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information v <br />