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<br />- M • • <br />MINED LAND RECLAMATION <br />Application tJorksheet/Checklist <br />.$c~~"~.a~ 2 Ca~ttr~~f: o.+ <br />Limited Impact (110) Name'` ,ls„lark a;>`~ <br />Special 10-Day (111) Complete Filed Oate 3 <br /> <br /> <br />d. <br />File No.M-~5-o2 <br />~ <br /> <br /> ITEhI COMPLETE ADEQUATE COMMENTS <br />App <br />1. lication Fonn: <br />Name of Operation <br /> <br />x <br /> <br />K <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) I <br />4. Address & Phone (General) <br />5. Person to Contact <br />I <br />b. Surface Owners <br />7. Mineral Owners <br />d. Source of Le al Ri ht-To-Enter <br />9 9 <br />y. Type of Mine/Substance <br />i <br />lU. General Location ~ Elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present Land Use <br />I <br />15. Proposed Future Use ' <br />16. Siynature <br /> <br />3 <br />