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_~; <br />Limited Impact (110) <br />Special 10-Day (111) <br />File No. <br />ITEM <br /> <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name <br />Complete Filed Date <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) No <br />4. Address & Phone {General) <br />5. Person to Contact <br />6. Surface Owners <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance <br />10. General Location & Elevation <br />( <br />/ <br />11. County I / <br />V <br />12. Acreage p / <br />lam <br />13. Fee / <br />(/ <br />14. Present Land Use <br />15. Proposed Future Use 1 / <br />(/ <br />16. Signature <br />