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~~ ~ , iii iiiiiiiiiiiiiiii <br />MINED LAND RECLAh1ATIUN <br />Application Worksheet/Checklist <br />DO MPihIC LMne CcnJfYr c{'~o.~ ~. <br />Limited Impact (11O) Name "Caen=- ,(" File No./'1-~s-oo8' <br />Special 10-Day (111) Complete Filed Date J n 3 4bS <br />ITEM CDMPLETE ADEQUATE COMMENTS <br />Application Form• <br />1. Name of Operation <br /> X ~ <br />2. Name of Applicant/Operator <br /> ~ K <br />3. Address & Phone (Local) <br /> ~ ~ <br />4. address & Phone (General) I <br /> ~ X <br />5. Person to Contact <br /> X ~ <br />6. Surface Owners <br /> ~ X <br />7. Mineral Owners ~ <br />8. Source of Legal Right-To-Enter X <br /> <br />9. Type of Mine/Substance `/ <br /> <br />/` X <br />10. General Location & Elevation <br /> <br />11. County <br /> tX <br />12. Acreage i <br /> X ~c <br />13. Fee <br />14. Present Land Use <br /> ~` k. <br />15. Proposed Future Use <br /> ~ ~ <br />16. Signature ~ <br />