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4/77- • IIIIIIIIIIIIIIIIIII <br />• <br />~tED LAi•ID RECLAi;4TI0.t <br />LL*SITED L~tPACT AitD SPEC?4L 10-DAY P°_ffiaIT 9PPLICATIO:T ~.'.EC:O;.IST <br />~ Fi1e :Io.~ ~Y :tame ~~-G~~(c.,- ~-~KCS. Date of Fi1i.^g (Completeness): <br />ITE.'~ COi~LcTE ADEQAATE COPL`SE:ITS <br />d~vlication Fora <br />1. name of operation <br />2. name of aonlicaat/operator <br />3. Address S phone (local offices) <br />w. Address G shone (general offices) I ~/'- <br />S. Person to contact <br />I <br />5. Surface oumers /~ <br />7. 2liaeral o;aaers <br />8. Type of nine/substance J <br />9. General location S elavatioa ~ 1~---I i <br />10. County ~ ~/- <br /> <br />il. Acreage I i ' <br />~~~ <br />I2. tee <br />13. Preserc land cse ~ ~ ~ <br />i4. Proposed future use ~ ~ <br />I.S. Signature <br />:~aas sad Exhibits <br />1. ~:hibit A -Legal descri?tion ~ <br />_. Ea.'sibit B - 2~'.:aiag plan ' ~ ' <br />3. Exhibit C - :~.ap ~ <br />L. Essibit D - '+t3=:dlife, idater Resources, <br />7egetation and Sai'_s in:or- <br />nation / <br />!// <br /> <br />i <br /> <br />S. :.4hibit - ?eclamatioa plan ~ <br />~ I <br />~ <br />