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~' <br />~ MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact 110(1) Operator: ~~ ~ ~Ac vwvr <br />Mine Name: <br />Mine ID.: - ubmittal Date: L~~r Q-~ <br />Application Form <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED ? i-o.esf5~ Q~t_vn <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED r <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - Location Map <br />EXHIBIT B - Legai Description '/ <br />EXHIBIT C - Affected Lands Map's <br />EXHIBIT D - Reclamation Plan ~ <br />EXHIBIT E - Notice to Owners of Affected and Ad]acent Lands / <br />