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;~ <br />• • ~IIII~~I~II~I~~~~I~ <br />sss <br />MINED LAND RECLAtMTIUN <br />Application Worksheet/Checklist <br />Limited Impact (11U) NameWc tern -r{~., ¢ Cv.,ft, Co, File No. ~3~~09 <br />Special 10-Day (111) Complete fled) Date Dec. aT IS ~3 <br />ITEhI <br />COMPLETE ADEQUATE COMMENTS <br />Application Fonn: <br />1. Name of Operation ~` <br />Z. Name of Applicant/Operator X x <br />3. Address & Phone (Local) V <br /> x / <br />4. Address & Phone (General) x ~ <br />5. Person to Contact X \/ <br />/~ <br />b. Surface Owners <br /> X <br />7. Mineral Owners <br />-~ <br />8. Source of Legal Right-To-Enter <br /> X X <br />U. Type of Mine/Substance <br /> X <br />10. General Location t» Elevation <br /> x <br />11. County <br /> x ,~ <br />12. Acreage <br /> ~ X <br />13. Fee <br /> X X <br />14. Present Land Use <br />15. Proposed Future Use `/ <br />16. Signature ~ ~ /`~~ S, ynur.,.-< <br />