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~~ ~- ` ~~ • • III INIIIIIIIIIIIII <br />999 <br />Limited Impact (110) <br />Special 10-Day (111) <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name gEt~,...~d. Q,r,k CJ„~,~,,, jFile No. p,-P., zll <br />Complete Filed Date i <br />ITEM COMPLETE ADEQUATE ', COMMENTS <br />Application Form• <br />1. Name of Operation <br />2. Name of Applicant/Operator ./ <br />3. Address & Phone (Local) ~ / <br />/ <br />4. Address & Phone (General) v. ~ <br />5. Person to Contact <br />/' / <br />6. Surface Owners <br />7. Mineral Owners ` / <br />/ <br />8. Source of Legal Right-To-Enter ~ awn-tax re~t,~ <br />9. Type of Mine/Substance v/ <br />10. General Location & Elevation / / <br />~/ <br />11. County v ~ <br />12. Acreage / / <br />/ <br />13. Fee. / <br />V / <br />/ <br />14. Present Land Use / <br />/ / <br />/ <br />15. Proposed Future Use / <br />V ~ <br />16. Signature / / <br />~5 <br /> <br />