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III IIIIIIIIIIIII III <br />999 <br />Limited Impact (110) <br />Special 10-Day (111) <br />• <br /> <br />MIMED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name a File No. ~T" /-70 <br />Complete filed ate q - 1~" S ~ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Surface Owners <br />1. Mineral Owners <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance <br />10. General Location & Elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present Land Use <br />15. Proposed Future Use <br />16. Signature <br />