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<br />DIVISION OF MINERALS AND GEOLOGY <br />Limited impact 110(2) <br />-/ Application WorksheetjChecklist <br />New App: V n/~ rrAmendrnment App: Conversion App: <br />Operator: McI~ 1~'P~;{'~,r .nIC~.V1 ~P_iot~Y Mine ID: Q~ -o~(p <br />Mine Name: UY~"~,YQ...Q.d ~15~4, ~S.iCc~S Submittal Date: c7I`~IgY <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />ITEMS 8 9 10 11 12 <br />COMPLETED <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP / '! <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />b. Critical Structures within 200 feet and offsite damage <br />c. Water Resources and Wildlife Statement (if provided) <br />