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]/]S APPLICATION CHECKLIST IIIIII'IIIIIIIIIIII_7 <br />LIMITED IMPACT (110) l/ NAME ~ 999__ <br />SPECIAL 10^DAY (111) _ COMPLETE (FI D) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />I. Name of operation <br />v <br />2. Name of applicant/operator v <br />3. Address b phone, local v <br />4. Address 6 phone, general r <br />5. Person to contact ~~ <br />6. Surface owners ~~ <br />], Mineral owners ~~ <br />8. Source of legal right-to-enter <br />9. Type of mine/substance ~~ <br />10. General location E elevation ~/ <br />11. County v <br />12. Acreage `~ <br />1 3. Fee Li <br />14. Present land use ~ <br />15• Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />L/ <br />EXHIBIT B - Mining Plan v <br />EXHIBIT C ^ Map <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information <br /> <br />