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.. _ <br />MINED LAND WILDLIFE QUESTIONAIRE <br />for limited impact and select regular mine applications <br />1. Name of Company(Mine: <br />2. Name/Address/Phone of Contact Person <br />3. Location of Mine: _ _ <br />(County, Township, Range, Section to nearest quarter quarter; Exhibit A-MLR appl.) <br />4. Nearest TownjCeneral Location: <br />S: ~:~Land Ownership'_(.Circle) 1. Private 2. BLM 3; USFS 4. Other <br />_ _6. Pres_.ent; Land";hse: _. ~___,____ _ - _ __ <br />7. Piop'osed7.F3na7 Land Use: <br />8. Type of Operation: 1. Surface 2. Underground <br />9. Minerals being mined: <br />10. Number and Description of Surface Acres Disturbed by Mining/not inc:Luding roads <br />(Exhibit D-MLR): <br />11. Miles of roads to be constructed: <br />12. Life of Mine (years): <br />13. Description of Operation and Reclamation -- Additional sheets may be attached <br />(Exhibits B b E-MLR)__ _ ___ _ _ _ _ <br /> <br />14. Please enclose Maps of Project Operation, Disturbance Areas and Reclamation (Exhibit <br />C.) This will expedite processing. Your cooperation is appreciated. <br />15, Prepared by:_ Date: <br /> <br />