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~ ~ III IIIIIIIIIIIII III <br />DIVISION OF MINERALS AND GEOLOGY <br />CONSTRUCTION MATERIALS <br />Limited Impact 110 Mining Operation <br />Application Worksheet/Checklist <br />New App: _~. Amendment App: <br />Operator: (Y1~I~P A. ~lPf~ <br />Mine Name: FP,~fPlD Y I -~ <br />APPLICATION FORM (Rule 1.6.2 and 1.6.3): <br />Conversion App: <br />Mine ID: (Yl -~DDD-D~~ <br />Submittal Date: 3IZ~D!) <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> / ~ V / ~ <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br /> / <br />t/ <br />v <br />/ ~ <br />ITEMS CONV/AMEND PERMITEE SIG <br />COMPLETED DESCP RESP <br /> 1/2 /3 / <br /> 4i5/6 / / <br /> ye/s~ <br />MAPS and EXHIBITS (Rule 6.2 & 6.3) <br />ADEQUACY COMMENTS <br />EXHIBIT A - 6.3.1 - LEGAL DESCRIPTION & LOCATION MAP ~/ <br />