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h/77} <br />• III IIIIIIIIIIIIIIII • <br />sss _ ____ <br />L{Y\/ .W YY.Y ~ <br />LItiIi ITED L"1PACT r1L'~D 52°CL4L i0-Da? P~~'•iIT AP°LZC2.T20:1 C3ECFI.IST <br />File Vo. ~=~:2 vasre ~~ Ca.K~v Date of Filing (Completeness} <br />ITE1 /~ ~ -~ I <br />i ILa COMPLETE I ADEQLTaTE C0~`SEITS <br />Application Form <br />1. Yame of operation <br />~ <br />2. :lame of apalicant/operator ~' <br />3. Address ~ phone (local offices) <br />4. Address S phone (general offices) I <br />5. Person to contact <br /> <br />5. Surface owners <br />.~- ' i <br />7. :Linera:L owners <br />8. Tppe of nine/substance <br />9. General location ~ elzvatioa <br />10. Couat9~ I ,~- <br />ll. Acreac;e I --- <br />12. Eee I `~ <br />l3. ?resettt land usa ~ ~- ~ <br />I ~ <br />~ <br />lb. Prono:;ed future use I ~ ~ <br />15. SI~naZUre ~ / <br />waps and Exhibits <br />1. Esitibit A - Leal descript_oa <br />`- <br />Z. Exhibit 3 - )iiaing plan <br />3 . Exaic. it C - 2•ap '' <br />+. Ex'aibic D - 'dildlirz, dater Resources, <br />7egetatioa and Soils into-- <br />nation <br />~- <br />If <br />7. Exhibit °_ - ?eciamation pion -- <br />