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/ • • <br />S <br />` • III III III III IIII III <br />999 <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />/ Application Worksheet/Checklist <br />New App: V Amendment App: ConversiongdApp: <br />Operator: 1~~,,,~ ~~/~~~~ Mine ID: // ~v// <br />Mine Name: l,/~paf F°~~,/71~Q~,,.f ~yo, ~ Submittal Date: ~- ~3 <br />APPLICATION FORM: <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> / <br />V / <br />V <br />/ / <br />V / <br />V ^~ <br />V <br /> <br />ITEMS <br />COMPLETED 7 8 9 10 11 12 <br /> 1 / <br />v / <br />V / <br />V 1 / <br />V ` ~ <br />V / <br />V <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP <br />I~ <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />~~` <br />b. Critical Structures within 200 feet and offsite damage <br />61~ <br />c. Water Resources and Wildlife Statement (if provided) <br />bK <br />