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•• ` . <br />~~ <br />MINED LAND WILDLIFE QUESTIONAIRE <br />for :Limited impact and select regular mine applications <br />1. Name of Company/M:Lne: <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 Town/General Location: <br />5. Land Ownership (Circle) 1. Private 2. BLM 3; USFS 4. Other <br />6. Present Land Use: <br />7. Proposed Final 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 including 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 />14. Please enclose Maps of Project Operation, Disturbance Areas and Reclamation (Exhibit <br />C.) This will expedite processing. Your cooperation is appreciated. <br />I5, Prepared by: Date <br />h.. 1 ~ }!~ <br />