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DIVISION OF MINERALS AND GEOLOGY <br />CONSTRUCTION MATERIALS <br />Limited Impact 110 Mining Operation <br />Application WorksheetJChecklist`~ <br />New App: n Amendment App: Conversion App: <br />Operator: ~~f"Jr/l5 ~~%n`~fY~2f~i`i~'1 (7n LLL~ / Mine ID: m7.a0Z0/'-~'~ <br />Mine Name: ~~ Qirl' Nn• ~ ,-~ Submittal Date: ~~~N~Oli ~ <br />APPLICATION FORM (Rule 1.6.2 and 1.6.3): <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br /> <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br /> ~ ~ ~/ / <br />ITEMS CONV/AMEND PERMITEE SIG <br />COMPLETED DESCP RESP <br /> ~2/3~ <br /> 4/q~e t~ <br /> / <br />7/ 8~ 9' <br />MAPS and EXHIBITS (Rule 6.2 & 6.3) <br />ADEQUACY COMMENTS <br />EXHIBIT A - 6.3.1 - LEGAL DESCRIPTION & LOCATION MAP ~/ <br />