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;.. <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />c ~ c 54..E Co. <br />Limited Impact (110) Name ed Ccn e~+ Qu ~' File No. _ S-o <br />Special 10-Day (111) Complete File Date ~}A „T,iSb's <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> ~ k <br />2. Name of Applicant/Operator k k <br /> <br />3. Address & Phone (Local) <br /> <br />4. Address & Phone (General) <br /> k <br />5. Person to Contact ~ k <br />6. Surface Owners <br /> <br />7. Mineral Owners <br />Z <br /> X ! <br />8. Source of Legal Right-To-Enter <br /> ~ <br />9. Type of Mine/Substance <br /> X X <br />10. General Location & Elevation x <br /> ~ <br />11. County <br /> X n <br />12. Acreage ~ <br /> X <br />13. Fee <br />14. Present Land Use x <br /> . ~ <br />15. Proposed Future Use ~ <br /> X <br />16. Signature <br /> x <br />