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/$ <br />LIMITED IMPACT (I10) !' <br />SPECIAL 10-DAY (I11) _ <br />ITEM <br />APPLICATION CHECKLIST <br />NAME ___l~~ <br />COMPLETE (FILED DATE <br />iii iii~iiiiiiiii iii <br />~~ FILE M /~ <br />G 2/~ 7C <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: Z <br />1. Name of operation <br />2. Name of applicant/operator / <br />[/ <br />3• Address b phone, local / <br />(/ <br />4. Address 6 phone, general / <br />v <br />5• Person to contact <br />6. Surface owners <br />7. Mineral owners ~ <br />8. Source of legal right-to-enter <br />9• Type of mine/substance <br />10. General location E elevation V <br />11. County ~" <br />12. Acreage / <br />v <br />13• Fee <br />14. Present land use <br />15• Proposed future use , / <br />16. Signature t/ <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />V <br />EXHIBIT B - Mining Pian / <br />EXHIBIT C - Map <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information , / <br />V <br />